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2012 Texas Medicaid Provider Procedures Manual

Gynecological and Reproductive Health and Family Planning Services Handbook : 3. Women’s Health Program (Title XIX Family Planning) : 3.3 Services, Benefits, Limitations, and Prior Authorization : 3.3.1 Family Planning Annual Exams

3.3.1
Family planning 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 and a WHP diagnosis code:
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:
New patient: Most appropriate E/M procedure code (99201–99205) with modifier FP and a WHP 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 WHP diagnosis code
Refer to:
Subsection 3.3, “Services, Benefits, Limitations, and Prior Authorization” in this handbook for the list of WHP diagnosis codes.

Texas Medicaid & Healthcare Partnership
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