TMPPM 2011 >2.3.1 Family Planning Annual Exams

An annual family planning exam consists of a comprehensive health history and physical examination, including medical laboratory evaluations as indicated, an assessment of the client's problems and needs, and the implementation of an appropriate contraceptive management plan.

Family planning providers must bill the most appropriate evaluation and management (E/M) visit procedure code for the complexity of the annual family planning examination provided. To bill an annual family planning examination, one of the following procedure codes must be billed with modifier FP and a family planning diagnosis code:


Procedure Codes
99201	99202	99203	99204	99205	99211	99212	99213	99214	99215

Important: Only the annual family planning examination requires modifier FP. All other family planning office visits do not. One annual family planning examination is allowed per year. Claims filed incorrectly may be denied.

The following table summarizes the uses for the E/M procedure codes and the corresponding billing requirements for the annual examination:


Billing Criteria	Frequency
New patient: Most appropriate E/M procedure code (99201-99205) with modifier FP and a family planning diagnosis code	One new patient E/M code every 3 years following the last E/M visit provided the client by that provider or a provider of the same specialty in the same group
Established patient: Most appropriate E/M procedure code (99211-99215) with modifier FP and a family planning diagnosis code	Once a year*
* The established patient procedure code will be denied if a new patient procedure code has been billed in the same year.

An annual family planning examination (billed with modifier FP) will not be reimbursed when submitted with the same date of service as a surgical procedure or an additional E/M visit.

If another condition requiring an evaluation and management (E/M) office visit beyond the required components for the annual examination is discovered, the provider may submit a claim for the additional visit using Modifier 25 to indicate that the client's condition required a significant, separately identifiable E/M service. Documentation supporting the provision of a significant, separately identifiable E/M service must be maintained in the client's medical record and made available to Texas Medicaid upon request.