Revised: 09-06-2013 Minnesota Family Planning Program (MFPP) Procedure Codes 00840 Anesth, surg low abdmn 00851 Anesth, tubal lig/transect 00920 Anesth, genitalia surgery 00921 Anesth, vasectomy 00950 Anesth, vaginal endoscopy 00952 Anesth, uterine endoscopy 11976 Removal of contracep cap 11981 Insert drug implant device 11982 Remove drug implant device 49320 Diag laparo separate proc 49321 Laparoscopy, biopsy 49329 Lap proc, abdm/per/omentum 52010 Cystoscopy & duct catheter 54500 Biopsy of testis, needle 54505 Biopsy of testis, incis 54865 Exploration of epididymis 54830 Excision epididymis lesion 54900 Fuse sperm ducts, unilateral 54901 Fuse sperm ducts, bilateral 55200 Vas cannul w/wo incis 55250 Vas, uni/bilat postop semen exam 55300 Prep for sperm duct x-ray 55400 Repair sperm duct 55450 Ligation sperm duct 55520 Excis sperm cord lesion 55530 Revise sperm cord veins 55535 Revise sperm cord veins abd 55540 Excis hernia & sperm veins 55600 Vesiculotomy 55605 Vesiculotomy; complicated 55680 Excis Mullerian duct cyst 55870 Electroejaculation 57150 Vag irrigate/med app tx 57160 Insert pessary sup device 57170 Fit diaphragm/cap 57410 Pelvic exam under anesth 57505 Endocervical curettage 57700 Revision of cervix
57720 plastic repair cervix 57800 Dilation of cervical canal 58100 Biopsy uterus lining 58120 Dilation & curettage 58140 Myomectomy abd approach 58145 Myomectomy vag approach 58300 Insertion IUD 58301 Remove IUD 58340 Inject for ut/tube x-ray 58345 Reopen fallopian tube 58350 Chromotubation oviduct 58400 Uterine suspension 58540 Hyseroplasty, (Strassman) 58555 Hysteroscopy, diagnostic 58558 Hysteroscopy, biopsy 58559 Hysteroscopy, lysis 58560 Hysteroscopy resect septum 58561 Hysteroscopy remove myoma 58565 Hysteroscopy bi tube cannul 58600 Ligate/transect tubal, ab/vag 58605 Lig/tran tubal uni/bi postpart same stay 58611 Ligation oviduct(s) 58615 Fal tube occlusion w device 58660 Laparoscopy lysis 58670 Lap w fulg ovid w/wo transect 58671 Lap w occlus ovid by device 58672 Laparoscopy fimbrioplasty 58673 Laparoscopy salpingostomy 58700 Salpingectomy 58740 Lysis of adhesions 58752 Revise ovarian tube(s) 58760 Fimbrioplasty 58770 Salpingostomy 58825 Transposition, ovary(s) 58900 Biopsy of ovary 58920 Wedge resec/bisect ovary uni/bi 74000 Rad exam, abd 1 anteropost 74740 Hysterosalpingography 74742 X-ray fallopian tube 76856 Echography pelvic complete
76857 Echography pelvic 76870 Echography scrotum 76872 Ultrasound transrectal 76948 Echo guide ova aspiration 77080 DXA axial 77081 DXA appendicular 80061 Lipid panel 80076 Hepatic function panel 81000 Urinalysis with microscopy 81001 Urinalysis auto w/scope 81002 Urinalysis nonauto no scope 81003 Urinalysis auto w/o scope 81004 Urinalysis Single Compon 81005 Urinalysis qual/semiquan 81006 Urine volume measurement 81007 Urinalysis for bacteriuria 81010 Urinalysis Con & Dilu Test 81011 Urinalysis H2ODep Test 81012 Urine H2O Dp Tst w Vso Rsp 81015 microscopic urine exam 81025 Urine Pregnancy Test 82270 Test feces for blood 82465 Assay serum cholesterol 82670 Estradiol 82746 Folic acid; serum 82947 Assay quantitative glucose 82951 Glucose tolerance test GTT 83000 Gn pituitary FSH bioassay 83001 Gonadotropin FSH 83002 Gonadotropin LH 83020 Hemoglobin assay 83986 ph body fluid assay 84146 Prolactin 84443 TSH 84702 hcg quantitative 84703 hcg qualitative 84830 Ovulation tests 85002 Bleeding time 85004 Automated diff wbc count 85007 Differential WBC count
85008 Nondifferential WBC count 85013 Spun microhematocrit 85014 Hematocrit 85018 Hemoglobin 85025 Auto hemogram diff WBC 85027 Auto CBC 85032 Manual cell count each 85049 Automated count platelet 85610 Prothrombin time 85651 Sedimentation rate non-auto 85652 Rbc sed rate, auto 85730 PTT 86592 Blood serology qualitative 86593 Blood serology quantitative 86631 Antibody; Chlamydia 86632 Antibody; Chlamydia, IgM 86687 Antibody; HTLV-I 86688 Antibody; HTLV-II 86689 HTLV/HIV confirm test 86695 Herpes simplex type 1 86696 Herpes simplex type 2 86701 HIV-1 86702 HIV-2 86703 HIV-1/HIV-2 single assay 86706 Hep B surface ab test 86781 Treponema pallidum, confirm 86803 Hep C antibody 87070 Bac cult not urine,bld/stool 87075 Culture bacteria specimen 87081 Culture bacteria screen 87086 Urine cult quan count 87088 Bac cult w isol &ID isolates 87109 Mycoplasma cult 87110 Culture chlamydia 87140 culture typing fluorescent 87181 Antibiotic sensitivity 87184 Antibiotic sensitivity 87205 Smear stain & interpret 87206 Smear stain & interpret 87207 Smear stain & interpret
87210 Smear stain & interpret 87252 Virus inoculate for test 87254 Virus inoculate shell vial 87255 Genet virus isolate, hsv 87270 Chylmd trach ag, dfa 87273 Herpes simplex 2, ag, if 87274 Herpes simplex ag, dfa 87285 Influenza b, ag, if 87320 Chylmd trach ag, eia 87340 Hep b surface ag, eia 87350 Infect antigen detect 87390 Infect antigen det HIV-1 87391 Hiv-2 ag, eia 87449 Ag detect nos, eia, mult 87490 Chylmd trach dna dir probe 87491 Chylmd trach dna amp probe 87492 Chylmd trach, dna, quant 87528 Hsv, dna, dir probe 87530 Hsv, dna, quant 87531 Hhv-6, dna, dir probe 87532 Hhv-6, dna, amp probe 87533 Hhv-6, dna, quant 87534 Hiv-1, dna, dir probe 87535 Hiv-1, dna, amp probe 87536 Hiv-1, dna, quant 87537 Hiv-2, dna, dir probe 87538 Hiv-2, dna, amp probe 87539 Hiv-2, dna, quant 87590 N.gonorrhoeae dna dir prob 87591 N.gonorrhoeae dna amp prob 87592 N.gonorrhoeae dna quant 87620 Hpv, dna, dir probe 87621 Hpv, dna, amp probe 87622 Hpv, dna, quant 87797 Detect agnt nos dna dir 87798 Detect agnt nos dna amp 87799 Detect agnt nos dna quant 87800 Detect agnt mult dna direc 87810 Chylmd trach assay w/optic 88141 Cytpath crv/vag interp
88142 Cytpath crv/vag t/layer 88143 Cytpath c/vag t/layer redo 88144 Cytpth c/vag t/layer auto 88145 Cytpth c/vag t/layer selct 88147 Cytpath c/vag automated 88148 Cytpath c/vag auto rescrn 88150 Cytopath, pap smear 88151 Cytopath interpret 88152 Cytopath cerv/vag auto 88153 Cytpath c/vag redo 88154 Cytpath c/vag select 88155 Cytopath pap smear 88156 TBS smear Bethesda System 88157 TBS smear Bethesda System 88158 Cytopath cerv/vag tbs auto 88160 Cytopathology 88161 Cytopathology 88162 Extensive cytopathology 88164 Cytpath tbs c/vag manual 88165 Cytpath tbs c/vag redo 88166 Cytpth tbs c/vag auto redo 88167 Cytpath tbs c/vag select 88174 Cytopath c/v auto in fluid 88175 Cytpth c/v auto fluid redo 88300 Level 1 surg path gross only 88302 Lev 2 surg path gross & micro appendix incidental fall tube sterilization 89300 Semen analy; include Huhner test 89321 Semen analysis 93975 Vascular study 93976 Dup scn flw art in&ven out 96372 Ther/proph/diag inj, sc/im 99078 Grp health ed 99201 Office/outpt visit new pt 99202 Office/outpt visit new pt 99203 Office/outpt visit new pt 99204 Office/outpt visit new pt 99205 Office/outpt visit new pt 99211 Office/outpt visit new pt 99212 Office/outpt visit est pt 99213 Office/outpt visit est pt
99214 Office/outpt visit est pt 99215 Office/outpt visit est pt 99241 Office consultation 99242 Office consultation 99243 Office consultation 99244 Office consultation 99245 Office consultation 99384 Prevent visit new 12-17 99385 Prevent visit new 18 39 99386 Prevent visit new 40 64 99394 Prevent visit est 12-17 99395 Prevent visit est 18 39 99396 Prevent visit est 40 64 99401 Prev counsel indv 15 min 99402 Prev counsel indv 30 min 99403 Prev counsel indv 45 min 99404 Prev counsel indv 60 min 99411 Prev counsel grp 30 min 99412 Prev counsel grp 60 min A4261 Cerv cap contracep A4266 Diaphragm A4267 Male condom A4268 Female condom A4269 Spermicide G0027 Semen analysis pres/mot H1010 Nonmed fam plan ed J1050 Medroxyprogesterone acetate 1mg inject J7300 copper IUD *J7302 Levonorgestrel IUD system *J7303 Contracept vaginal ring *J7304 Contracept patch *J7306 Levonorgestrel imp system J7307 Etonogestrel impl system Q0090 Levonorgestrel IUD system (13.5mg) Q0091 Pap smear *S4989 Contracept IUD *S4993 Contracept BC pills T1013 Oral language interp *Indicates the HCPCS code requires an NDC dispensing unit and the quantity when billing MHCP.
Secondary MFPP Procedure Codes Code/Range Description J0561 Inj penicillin G benz to 2.4 mil units *J0696 Inj ceftriaxone sodium *J8499** Prescription drug, oral, NOS Use to report CDC recommended drugs for treatment of STIs when dispensed in the office, for example Amoxicillin, Cefixime, Ciprofloxacin, Clindamycin, Clotrimazole, Doxycycline, Fluconazole, Metronidazole, Nitrofurantoin, Ofloxacin, Sulfa-methoxazole/Trimethoprim, Terconazole. List the drug, dosage and number of tablets dispensed in the comments section of the services tab for that individual service line in MN ITS *Q0144 Azithromycin, oral capsule 10060 Incis & drain abscess 10140 Incis & drain hematoma 17110 Wart destruction 54050 Destroy penis lesions, chem 54056 Destroy penis lesions, cryo 56501 Destroy vulva lesions 57061 Destroy vaginal lesions 57452 Colposcopy cervix incl up/adj vagina 57454-57456 Colposcopy, w bio cervix 57460-57461 Colposcopy, w loop biop cervix conization 57510-57511 Cautery of cervix; 88305 Level IV - Surg path, gross and micro 88307 Level V - Surg path, gross and micro *Indicates the HCPCS code requires an NDC when billing MHCP. Refer to NDC Reporting Clarification for additional information. **In addition to the NDC, J8499 continues to require the drug, dosage and number of tablets dispensed in the comments.