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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 : 3.3.2 Other Family Planning Office or Outpatient Visits

3.3.2
WHP only covers office or other outpatient family planning visits if the primary purpose of the visit is related to contraceptive management, as indicated by the allowable diagnosis codes previously listed. WHP does not cover office or other outpatient family planning visits when the primary purpose of the visit is not related to contraceptive management, such as visits for the purpose of pregnancy testing only, sexually transmitted infection testing, or a repeat Pap test after an abnormal result.
A provider is allowed to bill clients for services that are not a benefit of WHP.
Refer to:
Subsection 1.5.9.1, “Client Acknowledgment Statement” in Section 1, “Provider Enrollment and Responsibilities” (Vol. 1. General Information).
For office or other outpatient family planning E/M visits, providers must bill one of the following procedure codes based on the complexity of the visit with a WHP family planning diagnosis code:
Important:
The following table summarizes the uses for the E/M procedure codes and the corresponding billing requirements for each type of visit:
New patient: Most appropriate E/M procedure code (99201–99205) with 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 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.
Family planning services provided during a WHP visit in which only family planning services were provided must be submitted with these procedure codes and the most appropriate informational procedure codes for services that were rendered.
The procedure codes in the previous table are allowed for routine contraceptive surveillance, family planning counseling and education, and contraceptive problems. Depending on the extent of the services provided during the office visit, providers may bill for the maximum allowable fees.
During any visit for a medical problem or follow-up visit the following must occur:

Texas Medicaid & Healthcare Partnership
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