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2012 Texas Medicaid Provider Procedures Manual

Gynecological and Reproductive Health and Family Planning Services Handbook : 4. Department of State Health Services (DSHS) Family Planning Program Services : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.1 Family Planning Annual Exams

4.2.1
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.
DSHS 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:
Refer to:
The following table summarizes the uses for the E/M procedure codes and the corresponding billing requirements for the annual examination:
New patient: Appropriate E/M procedure code with modifier FP
One new patient E/M code every three years following the last E/M visit provided to the client by that provider or a provider of the same specialty in the same group
Established patient: Appropriate E/M procedure code with modifier FP
For appropriate claims processing, providers are encouraged to use a family planning diagnosis code to bill the annual family planning exam.
Refer to:
Subsection 4.2, “Services, Benefits, Limitations, and Prior Authorization” in this handbook for the list of family planning diagnosis codes.
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.

Texas Medicaid & Healthcare Partnership
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