Medicaid Family Planning Waiver Services CPT Codes and ICD-10 Diagnosis Codes

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1 CPT Code Description of Covered Codes Evaluation and Management 99384FP 99385FP Family planning new visit 99386FP 99394FP 99395FP Family planning established visit 99396FP 99401FP HIV counseling (pre-test) 15 min 99402FP HIV counseling (post-test) 30 min 99403FP Family planning counseling visit 99211FP Family planning supply visit Extended family planning services-new patient (treatment of STI) Extended family planning services-established patient (treatment of STI) Medication/Device A4264 Essure device J1050 Injection medroxyprogesterone acetate (Depo-Provera) J7300 Intrauterine copper device (Paraguard) J7301 SKYLA 13.5MG J7302 Levonorgestrel-releasing intrauterine device (Mirena and Liletta) J7307 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 Pelvic examination under anesthesia 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) Surgical laparoscopy, with occlusion of oviducts by device (e.g. band, clip, or Falope ring) Radiological supervision and interpretation x-ray of uterine tubes and ovaries Page 1 of 6

2 76856 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 Herpes simplex, type Antibody; HIV Antibody; HIV Antibody; 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 Smear, primary source, with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types; (gonorrhea) Smear, primary source, with interpretation; (chlamydia) Smear, primary source, wet mount isolation, with stain Page 2 of 6

3 87252 Virus identification; tissue culture inoculation & observation Infectious agent antigen detection by immunofluorescent technique, chlamydia trachomatis Infectious agent antigen detection by immunofluorescent technique, herpes simplex virus type Infectious agent antigen detection by immunofluorescent technique, herpes simplex virus type Hepatitis B surface antigen (HBsAg) Hepatitis B surface antigen (HBsAg) neutralization Hepatitis Be antigen (HBeAg) HIV 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 Gardnerella vaginalis, amplified 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 HIV-1, direct probe technique HIV-1, 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 Trichomonas vaginitis, direct probe technique Trichomonas vaginitis, amplified probe technique Infectious agent antigen detection by immunoassay with direct optical observation; chlamydia trachomatis Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae Cytopathology, cervical or vaginal (any system) requiring physician interpretation Cytopathology, cervical or vaginal (preservative fluid) under physician supervision Cytopathology, cervical or vaginal with manual screen & re-screen under physician supervision Cytopathology, slides, cervical or vaginal, manual screen under physician supervision Cytopathology, slides, cervical or vaginal with manual screening and computerassisted rescreen under physician supervision Cytopathology, slides, with manual screen & re-screen under physician supervision Cytopathology, slides with manual screen & computer-assisted re-screening using cell selection and review under physician supervision Page 3 of 6

4 88155 Cytopathology, slides, cervical or vaginal, with definitive hormonal evaluation Cytopathology, slides, cervical or vaginal, (Bethesda System); with manual screening under physician supervision Cytopathology. slides, cervical or vaginal (Bethesda System);with manual screen & rescreen under physician supervision Cytopathology, slides, cervical or vaginal (Bethesda System), manual screen & computer-assisted re-screen under physician supervision Cytopathology, slides, cervical or vaginal, (Bethesda System), using cell selection and review under physician supervision Cytopathology, cervical or vaginal, (any reporting system), collected in preservative fluid, automated thin layer preparation, screen by automated system, under physician supervision With screen by automated system and manual rescreening or review, under physician supervision Level II surgical pathology, gross and microscopic (sterilization) Level IV surgical pathology, gross and microscopic (colposcopy) ICD-10 Code Description of Covered Diagnosis Codes A51.0 Primary genital syphilis A51.1 Primary anal syphilis A51.2 Primary syphilis of other sites A51.5 Early syphilis, latent A51.9 Early syphilis, unspecified A53.9 Syphilis, unspecified A54.00 Gonococcal infection of lower genitourinary tract, unspecified A54.01 Gonococcal cystitis and urethritis, unspecified A54.02 Gonococcal vulvovaginitis, unspecified A54.03 Gonococcal cervicitis, unspecified A54.09 Other gonococcal infection of lower genitourinary tract, unspecified A54.24 Gonococcal female pelvic inflammatory disease A54.29 Other gonococcal genitourinary infections A54.5 Gonococcal pharyngitis A54.6 Gonococcal infection of anus and rectum A54.9 Gonococcal infection, unspecified A56.00 Chlamydial infection of lower genitourinary tract -unspecified A56.01 Chlamydial cystitis and urethritis A56.02 Chlamydial vulvovaginitis A56.09 Other chlamydial infection of lower genitourinary tract A56.11 Chlamydial female pelvic inflammatory disease A56.19 Other chlamydial genitourinary infection A56.2 Chlamydial infection of genitourinary tract, unspecified A56.3 Chlamydial infection of anus and rectum A56.4 Chlamydial infection of pharynx A56.8 Sexually transmitted chlamydial infection of other sites A59.00 Urogenital trichomoniasis, unspecified A59.01 Trichomonal vulvovaginitis Page 4 of 6

5 A59.03 Trichomonal cystitis and urethritis A59.09 Other urogenital trichomoniasis A60.00 Herpesviral infection of urogenital system, unspecified A60.03 Herpesviral cervicitis A60.04 Herpetic vulvovaginitis A60.1 Herpesviral infection of perianal skin and rectum A60.9 Anogenital herpesviral infection, unspecified A63.0 Anogenital (venereal) warts A63.8 Other specified predominantly sexually transmitted diseases A64 Unspecified sexually transmitted disease A74.89 Other chlamydial diseases A74.9 Chlamydial infection, unspecified B37.3 Candidiasis of vulva and vagina B37.4 Candidiasis of other urogenital sites B07.8 Other viral warts B07.9 Viral wart, unspecified N34.1 Nonspecific urethritis N86 Erosion and ectropion of cervix uteri N87.0 Mild cervical dysplasia N87.1 Moderate cervical dysplasia N87.9 Dysplasia of cervix uteri, unspecified N88.0 Leukoplakia of cervix uteri Atypical squamous cells of undetermined significance on cytologic smear of cervix R (ASC-US) Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of cervix (ASC-H) R R Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL) R High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL) R Cytologic evidence of malignancy on smear of cervix R Unsatisfactory cytologic smear of cervix R Satisfactory cervical smear but lacking transformation zone R Other abnormal cytological findings on specimens from cervix uteri R Unspecified abnormal cytological findings in specimens from cervix uteri R Atypical squamous cells of undetermined significance on cytologic smear of vagina (ASC-US) Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of vagina (ASC-H) R R Low grade squamous intraepithelial lesion on cytologic smear of vagina (LGSIL) R High grade squamous intraepithelial lesion on cytologic smear of vagina (HGSIL) R Cytologic evidence of malignancy on smear of vagina R Unsatisfactory cytologic smear of vagina R Other abnormal cytological findings on specimens from vagina R Unspecified abnormal cytological findings in specimens from vagina R87.7 Abnormal histological findings in specimens from female genital organs R Cervical high risk human papillomavirus (HPV) DNA test positive R Vaginal high risk human papillomavirus (HPV) DNA test positive R Cervical low risk human papillomavirus (HPV) DNA test positive Page 5 of 6

6 R Vaginal low risk human papillomavirus (HPV) DNA test positive R87.89 Other abnormal findings in specimens from female genital organs R87.9 Unspecified abnormal finding in specimens from female genital organs Z Encounter for gynecological examination (general) (routine) with abnormal findings Z Encounter for gynecological examination (general) (routine) without abnormal findings Encounter for cervical smear to confirm findings of recent normal smear following initial abnormal smear Z01.42 Z11.51 Encounter for screening for human papillomavirus (HPV) Z12.4 Encounter for screening for malignant neoplasm of cervix Z Encounter for initial prescription of contraceptive pills Z Encounter for prescription of emergency contraception Z Encounter for initial prescription of injectable contraceptive Z Encounter for initial prescription of intrauterine contraceptive device Z Encounter for initial prescription of other contraceptives Z30.02 Counseling and instruction in natural family planning to avoid pregnancy Z30.09 Encounter for other general counseling and advice on contraception Z30.2 Encounter for sterilization Z30.41 Encounter for surveillance of contraceptive pills Z30.42 Encounter for surveillance of injectable contraceptive Z Encounter for insertion of intrauterine contraceptive device Z Encounter for routine checking of intrauterine contraceptive device Z Encounter for removal of intrauterine contraceptive device Z for removal and reinsertion of intrauterine contraceptive device Z30.9 Encounter for contraceptive management, unspecified Z32.00 Encounter for pregnancy test, result unknown Z32.01 Encounter for pregnancy test, result positive Z32.02 Encounter for pregnancy test, result negative Page 6 of 6

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