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 99201 99211 A4264 J1050 J7300 J7301 J7302 J7307 00840 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 00851 Anesthesia for tubal ligation/transection 11976 Removal of Implantable Contraceptive Capsules 11981 Insertion, non-biodegradable drug delivery implant 11982 Removal, non-biodegradable drug delivery implant 11983 Removal with reinsertion, non-biodegradable drug delivery implant 57170 Diaphragm or Cervical Cap fitting with instructions 57452 Colposcopy of the cervix 57454 Colposcopy with biopsy(s) of the cervix and endocervical curettage 57460 Colposcopy with loop electrode biopsy(s) 58300 Insertion of Intrauterine Device 58301 Removal of Intrauterine Device 58340 Catheterization and introduction of saline or contrast material for saline infusion for hysterosalpingography 58565 Bilateral fallopian tube occlusion by permanent implants 58600 Ligation or transection of fallopian tube(s) 58615 Occlusion of fallopian tube(s) by device (e.g. band, clip, Falope ring) 58670 Surgical laparoscopy, with fulguration of oviducts (with or without transection) Page 1 of 6
58671 Surgical laparoscopy, with occlusion of oviducts by device (e.g. band, clip, or Falope ring) 74740 Radiological and interpretation x-ray of uterine tubes and ovaries 76856 Ultrasound of pelvis, non-obstetric (to check placement of intrauterine devices) 76882 Ultrasound of extremity, limited, anatomic specific (to check for implantable contraceptive device) Laboratory 81001 Automated, with microscopy 81002 Non-automated, without microscopy 81003 Automated, without microscopy 81005 Urinalysis; Qualitative or semi-qualitative 81007 Urinalysis; bacteriuria screen, by kit 81015 Urinalysis; bacteriuria screen, microscopic only 81025 Urine pregnancy test, by visual color comparison 82947 Glucose; quantitative, blood 84702 Gonadotropin, chorionic (hcg); quantitative 84703 Gonadotropin, chorionic (hcg); qualitative 85007 Blood count; manual differential WBC count 85014 Hematocrit 85018 Hemoglobin 86255 Fluorescent antibody; screen, each antibody (HIV & Herpes) 86382 Neutralization test, viral 86403 Rubella screen (IgG) 86580 Tuberculosis, intradermal 86592 Syphilis test; qualitative (e.g., VDRL, RPR,ART) 86593 Syphilis test; quantitative 86689 HTLV or HIV antibody, confirmatory test (western blot) 86694 Herpes simplex, non-specific type test 86695 Herpes simplex, type I 86701 HIV-1 86703 HIV-1 and HIV-2, single assay 86706 Hepatitis B surface antibody (HBsAb) 86707 Hepatitis Be antibody (HBeAb) 86762 Rubella titer 86803 Hepatitis C antibody 87070 Culture, bacterial, definitive; any other source (GC) 87075 Culture, bacterial, any source; anaerobic (isolation) 87081 Culture, bacterial, screening only (GC) 87086 Culture, bacterial, urine; quantitative, colony count 87088 Culture, bacterial, urine; quantitative colony count, with isolation and presumptive identification of each isolate 87110 Culture, chlamydia 87164 Dark field examination, any source, includes specimen collection 87205 Neisseria gonorrhoeae smear 87206 Smear, primary source, with interpretation; (chlamydia) 87210 Smear, primary source, wet mount isolation, with stain 87252 Virus identification; tissue culture inoculation & observation 87340 Hepatitis B surface antigen (HBsAg) 87350 Hepatitis Be antigen (HBeAg) Page 2 of 6
87480 Candida species, direct probe technique 87481 Candida species, amplified probe technique 87490 Chlamydia trachomatis, direct probe technique 87491 Chlamydia trachomatis, amplified probe technique 87510 Gardnerella vaginalis, direct probe technique 87515 Hepatitis B virus, direct probe technique 87516 Hepatitis B virus, amplified probe technique 87520 Hepatitis C virus, direct probe technique 87521 Hepatitis C virus, amplified probe technique 87522 Hepatitis C virus, quantification 87528 Herpes simplex virus, direct probe technique 87529 Herpes simplex virus, amplified probe technique 87590 Neisseria gonorrhoeae, direct probe technique 87591 Neisseria gonorrhoeae, amplified probe technique 87623 HPV low-risk type detection test 87624 HPV high-risk type detection test 88141 Cytopathology, cervical or vaginal (any system) requiring physician interpretation 88142 Cytopathology, cervical or vaginal (preservative fluid) under 88143 Cytopathology, cervical or vaginal with manual screen & rescreen under 88150 Cytopathology, slides, cervical or vaginal, manual screen under Cytopathology, slides, cervical or vaginal with manual 88152 screening and computer-assisted rescreen under physician 88153 Cytopathology, slides, with manual screen & re-screen under Cytopathology, slides with manual screen & computerassisted 88154 re-screening using cell selection and review under 88155 Cytopathology, slides, cervical or vaginal, with definitive hormonal evaluation 88164 Cytopathology, slides, cervical or vaginal, (Bethesda System); with manual screening under Cytopathology. slides, cervical or vaginal (Bethesda 88165 System);with manual screen & re-screen under physician Cytopathology, slides, cervical or vaginal (Bethesda System), 88166 manual screen & computer-assisted re-screen under Cytopathology, slides, cervical or vaginal, (Bethesda 88167 System), using cell selection and review under physician Cytopathology, cervical or vaginal, (any reporting system), 88174 collected in preservative fluid, automated thin layer preparation, screen by automated system, under physician 88175 With screen by automated system and manual rescreening or review, under 88302 Level II surgical pathology, gross and microscopic (sterilization) Page 3 of 6
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 622.0 Erosion and ectropion of cervix 622.10 Dysplasia of cervix, unspecified 622.11 Mild dysplasia of cervix 622.12 Moderate dysplasia of cervix 622.2 Leukoplakia of cervix (uteri) 795.00 Abnormal glandular Pap smear of cervix 795.01 795.02 795.03 795.04 795.05 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 795.06 Pap smear of cervix with cytologic evidence of malignancy 795.07 Satisfactory cervical smear but lacking transformation zone 795.08 Unsatisfactory cervical cytology smear 795.09 Other abnormal Pap smear of cervix and cervical HPV Page 4 of 6
795.10 Abnormal glandular PAP smear of vagina 795.11 Pap smear of vagina with atypical squamous cells of Pap smear of vagina with atypical squamous cells cannot 795.12 exclude high grade squamous intraepithelial lesion (ASC-H) 795.13 Pap smear of vagina with low grade squamous intraepithelial 795.14 Pap smear of vagina with high grade squamous intraepithelial lesion (HGSIL) 795.15 Vaginal high risk human papillomavirus (HPV) DNA test 795.16 Pap smear of vagina with cytologic evidence of malignancy 795.18 Unsatisfactory vaginal cytology smear 795.19 Other abnormal Pap smear of vagina and vaginal HPV Diagnosis Codes to be used with Laboratory Procedures 054.10 Genital herpes, unspecified 054.11 Herpetic vulvovaginitis 054.12 Herpetic ulceration of vulva 079.98 Unspecified chlamydial infection 078.10 Viral warts, unspecified 078.11 Condyloma acuminatum 078.88 Other specified diseases due to chlamydiae 079.98 Unspecified chlamydial infection 091.0 Genital syphilis, primary 091.2 Other primary syphilis 092.0 Early syphilis, latent, serological relapse after treatment 092.9 Early syphilis, latent, unspecified 098.0 Acute gonococcal infection of the lower genitourinary tract 098.10 Gonococcal infection (acute) of the upper genitourinary tract, site unspecified 098.11 Gonococcal cystitis (acute) 098.15 Gonococcal cervicitis (acute) 098.16 Gonococcal endometritis (acute) 098.17 Gonococcal salpingitis, specified as acute 099.41 Chlamydia trachomatis 099.51 Other venereal diseases due to Chlamydia trachomatis- Pharynx 099.8 Other specified venereal disease 099.9 Venereal disease, unspecified 112.1 Candidiasis of vulva and vagina 131.00 Urogenital trichomoniasis, unspecified 131.01 Trichomonal vulvovaginitis 131.02 Trichomonal urethritis 622.0 Erosion and ectropion of cervix 622.10 Dysplasia of cervix, unspecified 622.11 Mild dysplasia of cervix 622.12 Moderate dysplasia of cervix 622.2 Leukoplakia of cervix (uteri) 795.00 Abnormal glandular Pap smear of cervix Page 5 of 6
795.01 Pap smear of cervix with atypical squamous cells of 795.02 Pap smear of cervix with atypical squamous cells of 795.03 Pap smear of cervix with low grade squamous intraepithelial 795.04 Pap smear of cervix with high grade squamous intraepithelial lesion (HGSIL) 795.05 Cervical high risk human papillomavirus (HPV) DNA test 795.06 Pap smear of cervix with cytologic evidence of malignancy 795.07 Satisfactory cervical smear but lacking transformation zone 795.08 Unsatisfactory cervical cytology smear 795.09 Other abnormal Pap smear of cervix and cervical HPV 795.10 Abnormal glandular PAP smear of vagina 795.11 Pap smear of vagina with atypical squamous cells of 795.12 Pap smear of vagina with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H) 795.13 Pap smear of vagina with low grade squamous intraepithelial 795.14 Pap smear of vagina with high grade squamous intraepithelial lesion (HGSIL) 795.15 Vaginal high risk human papillomavirus (HPV) DNA test 795.16 Pap smear of vagina with cytologic evidence of malignancy 795.18 Unsatisfactory vaginal cytology smear 795.19 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 099.9 Venereal disease, unspecified Page 6 of 6