TMPPM 2011 >4.3.1 Titles V and XX 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.

Titles V and XX family providers must bill the most appropriate 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:


Procedure Codes	Title V Fee	Title XX Fee
99201	$22.64	$22.64
99202	$35.73	$35.73
99203	$48.28	$48.28
99204	$70.64	$70.64
99205	$87.83	$87.83
99211	$11.73	$11.73
99212	$19.64	$19.64
99213	$29.52	$29.52
99214	$41.46	$41.46
99215	$63.83	$63.83

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: Procedure codes 99201-99205 with modifier FP	One new patient E/M code every three 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: Procedure codes 99211-99215 with modifier FP	Once a year*
* The established patient procedure code will be denied if a new patient procedure code has been billed for the annual examination in the same year.

For appropriate claims processing, providers are encouraged to use a family planning diagnosis code to bill the annual family planning exam for Titles V and XX clients.

An annual family planning examination (billed with modifier FP) will not be reimbursed when submitted with the same date of service as an additional E/M visit. If another condition requiring an E/M office visit beyond the required components for an office visit, family planning visit, or surgical procedure 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.