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20.7.2.1 Limitations
An annual family planning examination or other family planning office or outpatient visit billed with the FP modifier is not considered for reimbursement when submitted with the same date of service as an additional evaluation and management visit. Providers may appeal denied claims using modifier 25 if the reason for the additional visit was for a separate, distinct service from the family planning visit. Documentation that supports the provision of a significant, separately identifiable evaluation and management service must be maintained in the client's medical record and made available to the Texas Medicaid Program upon request.
Procedure codes 1-99204, 1-99214, and 1-J7300 are the only allowable codes for RHCs and FQHCs. RHCs providers must bill with modifiers AJ, AM, SA, or U7, and must use the family planning provider identifier.
Up to three encounter rates per calendar year per client may be reimbursed to FQHCs for family planning visits when only family planning services occurred during the visit. Providers must use procedure code 1-J7300, 1-99204, or 1-99214 to receive an encounter rate reimbursement for visits in which only family planning services were provided. For any family planning service other than an intrauterine device (IUD) or an annual exam with a new patient, FQHCs must bill procedure code 1-99214 with the claim to receive an encounter rate reimbursement. This includes family planning services that are not annual exams and visits where only an injection is provided.
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