Medicaid Family Planning Waiver Services CPT Codes and ICD-9 Diagnosis Codes

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1 Family Planning Waiver Services CPT Codes and ICD-9 Diagnosis Codes CPT Code Description of Covered Codes Evaluation and Management 99384FP 99385FP 99386FP 99394FP 99395FP 99396FP 99401FP 99402FP 99403FP 99211FP A4264 J1050 J7300 J7301 J7302 J Family Planning New/Established Visit HIV counseling (pre-test) 15 min HIV counseling (post-test) 30 min Family Planning Counseling Visit Family Planning Supply Visit Extended family planning services-new patient (treatment of STI) Extended family planning services-established patient (Treatment of STI) Medication/Device Essure device Injection Medroxyprogesterone Acetate (Depo-Provera) Intrauterine Copper Device (Paraguard) SKYLA 13.5MG Levonorgestrel-Releasing Intrauterine Device (Mirena) Etonogestrel implant system, including implant and supplies (Implanon) Anesthesia, Surgical and Radiology Anesthesia For Intraperitoneal Procedures In Lower Abdomen Including Laparoscopy Anesthesia for tubal ligation/transection Removal of Implantable Contraceptive Capsules Insertion, non-biodegradable drug delivery implant Removal, non-biodegradable drug delivery implant Removal with reinsertion, non-biodegradable drug delivery implant Diaphragm or Cervical Cap fitting with instructions Colposcopy of the cervix Colposcopy with biopsy(s) of the cervix and endocervical curettage Colposcopy with loop electrode biopsy(s) Insertion of Intrauterine Device Removal of Intrauterine Device Catheterization and introduction of saline or contrast material for saline infusion for hysterosalpingography Bilateral fallopian tube occlusion by permanent implants Ligation or transection of fallopian tube(s) Occlusion of fallopian tube(s) by device (e.g. band, clip, Falope ring) Surgical laparoscopy, with fulguration of oviducts (with or without transection) Page 1 of 6

2 58671 Surgical laparoscopy, with occlusion of oviducts by device (e.g. band, clip, or Falope ring) Radiological and interpretation x-ray of uterine tubes and ovaries Ultrasound of pelvis, non-obstetric (to check placement of intrauterine devices) Ultrasound of extremity, limited, anatomic specific (to check for implantable contraceptive device) Laboratory Automated, with microscopy Non-automated, without microscopy Automated, without microscopy Urinalysis; Qualitative or semi-qualitative Urinalysis; bacteriuria screen, by kit Urinalysis; bacteriuria screen, microscopic only Urine pregnancy test, by visual color comparison Glucose; quantitative, blood Gonadotropin, chorionic (hcg); quantitative Gonadotropin, chorionic (hcg); qualitative Blood count; manual differential WBC count Hematocrit Hemoglobin Fluorescent antibody; screen, each antibody (HIV & Herpes) Neutralization test, viral Rubella screen (IgG) Tuberculosis, intradermal Syphilis test; qualitative (e.g., VDRL, RPR,ART) Syphilis test; quantitative HTLV or HIV antibody, confirmatory test (western blot) Herpes simplex, non-specific type test Herpes simplex, type I HIV HIV-1 and HIV-2, single assay Hepatitis B surface antibody (HBsAb) Hepatitis Be antibody (HBeAb) Rubella titer Hepatitis C antibody Culture, bacterial, definitive; any other source (GC) Culture, bacterial, any source; anaerobic (isolation) Culture, bacterial, screening only (GC) Culture, bacterial, urine; quantitative, colony count Culture, bacterial, urine; quantitative colony count, with isolation and presumptive identification of each isolate Culture, chlamydia Dark field examination, any source, includes specimen collection Neisseria gonorrhoeae smear Smear, primary source, with interpretation; (chlamydia) Smear, primary source, wet mount isolation, with stain Virus identification; tissue culture inoculation & observation Hepatitis B surface antigen (HBsAg) Hepatitis Be antigen (HBeAg) Page 2 of 6

3 87480 Candida species, direct probe technique Candida species, amplified probe technique Chlamydia trachomatis, direct probe technique Chlamydia trachomatis, amplified probe technique Gardnerella vaginalis, direct probe technique Hepatitis B virus, direct probe technique Hepatitis B virus, amplified probe technique Hepatitis C virus, direct probe technique Hepatitis C virus, amplified probe technique Hepatitis C virus, quantification Herpes simplex virus, direct probe technique Herpes simplex virus, amplified probe technique Neisseria gonorrhoeae, direct probe technique Neisseria gonorrhoeae, amplified probe technique HPV low-risk type detection test HPV high-risk type detection test Cytopathology, cervical or vaginal (any system) requiring physician interpretation Cytopathology, cervical or vaginal (preservative fluid) under Cytopathology, cervical or vaginal with manual screen & rescreen under Cytopathology, slides, cervical or vaginal, manual screen under Cytopathology, slides, cervical or vaginal with manual screening and computer-assisted rescreen under physician Cytopathology, slides, with manual screen & re-screen under Cytopathology, slides with manual screen & computerassisted re-screening using cell selection and review under Cytopathology, slides, cervical or vaginal, with definitive hormonal evaluation Cytopathology, slides, cervical or vaginal, (Bethesda System); with manual screening under Cytopathology. slides, cervical or vaginal (Bethesda System);with manual screen & re-screen under physician Cytopathology, slides, cervical or vaginal (Bethesda System), manual screen & computer-assisted re-screen under Cytopathology, slides, cervical or vaginal, (Bethesda System), using cell selection and review under physician Cytopathology, cervical or vaginal, (any reporting system), collected in preservative fluid, automated thin layer preparation, screen by automated system, under physician With screen by automated system and manual rescreening or review, under Level II surgical pathology, gross and microscopic (sterilization) Page 3 of 6

4 88305 Level IV surgical pathology, gross and microscopic (colposcopy) Diagnosis Codes to be used with Family Planning Waiver Services ICD-9 Code Description of Covered Codes V25.01 Prescription of oral contraceptives V25.02 Initiation of other contraceptive measures V25.03 Encounter for emergency contraceptive counseling and prescription V25.04 Counseling and instruction in natural family planning to avoid pregnancy V25.09 Other family planning advice V25.11 Encounter for insertion of IUD V25.12 Encounter for removal of IUD V25.13 Encounter for removal and replacement of IUD V25.2 Sterilization V25.41 Surveillance of previously prescribed contraceptive method- V25.42 contraceptive pill Surveillance of previously prescribed contraceptive method- IUD V25.43 Implantable subdermal contraceptive V25.49 Other contraceptive device V25.5 Insertion of implantable subdermal contraceptive V25.9 Unspecified contraceptive management V72.31 Routine gynecological examination V72.32 Encounter for Pap cervical smear to confirm findings of recent normal smear following initial abnormal smear V76.2 Routine cervical Pap smear Diagnosis Codes to be used with Sterilization Procedures V25.2 Sterilization Diagnosis Codes to be used with Colposcopies Erosion and ectropion of cervix Dysplasia of cervix, unspecified Mild dysplasia of cervix Moderate dysplasia of cervix Leukoplakia of cervix (uteri) Abnormal glandular Pap smear of cervix Pap smear of cervix with atypical squamous cells of Pap smear of cervix with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H) Pap smear of cervix with low grade squamous intraepithelial Pap smear of cervix with high grade squamous intraepithelial lesion (HGSIL) Cervical high risk human papillomavirus (HPV) DNA test Pap smear of cervix with cytologic evidence of malignancy Satisfactory cervical smear but lacking transformation zone Unsatisfactory cervical cytology smear Other abnormal Pap smear of cervix and cervical HPV Page 4 of 6

5 Abnormal glandular PAP smear of vagina Pap smear of vagina with atypical squamous cells of Pap smear of vagina with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H) Pap smear of vagina with low grade squamous intraepithelial Pap smear of vagina with high grade squamous intraepithelial lesion (HGSIL) Vaginal high risk human papillomavirus (HPV) DNA test Pap smear of vagina with cytologic evidence of malignancy Unsatisfactory vaginal cytology smear Other abnormal Pap smear of vagina and vaginal HPV Diagnosis Codes to be used with Laboratory Procedures Genital herpes, unspecified Herpetic vulvovaginitis Herpetic ulceration of vulva Unspecified chlamydial infection Viral warts, unspecified Condyloma acuminatum Other specified diseases due to chlamydiae Unspecified chlamydial infection Genital syphilis, primary Other primary syphilis Early syphilis, latent, serological relapse after treatment Early syphilis, latent, unspecified Acute gonococcal infection of the lower genitourinary tract Gonococcal infection (acute) of the upper genitourinary tract, site unspecified Gonococcal cystitis (acute) Gonococcal cervicitis (acute) Gonococcal endometritis (acute) Gonococcal salpingitis, specified as acute Chlamydia trachomatis Other venereal diseases due to Chlamydia trachomatis- Pharynx Other specified venereal disease Venereal disease, unspecified Candidiasis of vulva and vagina Urogenital trichomoniasis, unspecified Trichomonal vulvovaginitis Trichomonal urethritis Erosion and ectropion of cervix Dysplasia of cervix, unspecified Mild dysplasia of cervix Moderate dysplasia of cervix Leukoplakia of cervix (uteri) Abnormal glandular Pap smear of cervix Page 5 of 6

6 Pap smear of cervix with atypical squamous cells of Pap smear of cervix with atypical squamous cells of Pap smear of cervix with low grade squamous intraepithelial Pap smear of cervix with high grade squamous intraepithelial lesion (HGSIL) Cervical high risk human papillomavirus (HPV) DNA test Pap smear of cervix with cytologic evidence of malignancy Satisfactory cervical smear but lacking transformation zone Unsatisfactory cervical cytology smear Other abnormal Pap smear of cervix and cervical HPV Abnormal glandular PAP smear of vagina Pap smear of vagina with atypical squamous cells of Pap smear of vagina with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H) Pap smear of vagina with low grade squamous intraepithelial Pap smear of vagina with high grade squamous intraepithelial lesion (HGSIL) Vaginal high risk human papillomavirus (HPV) DNA test Pap smear of vagina with cytologic evidence of malignancy Unsatisfactory vaginal cytology smear Other abnormal Pap smear of vagina and vaginal HPV V72.40 Pregnancy examination or test, pregnancy unconfirmed V72.41 Pregnancy examination or test, negative result V72.42 Pregnancy examination or test, results V73.81 Spec screen exam HPV V76.2 Routine cervical Papanicolaou (Pap) smear Venereal disease, unspecified Page 6 of 6

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