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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 : 4.2.2 Family Planning Office or Outpatient Visits

4.2.2
Other family planning E/M visits are allowed for routine contraceptive surveillance, family planning counseling and education, contraceptive problems, suspicion of pregnancy, genitourinary infections, and evaluation of other reproductive system symptoms.
During any visit for a medical problem or follow-up visit, the following must occur:
For general family planning visits, DSHS Family Planning Program Providers must bill one of the following, most appropriate E/M procedure code:
Procedure codes 99211, 99212, 99213, and 99214 are limited to 4 services per year when billed with a family planning diagnosis code.
The following table summarizes the uses for the E/M procedure codes and the corresponding billing requirements for general family planning office or outpatient visits:
New patient: Appropriate E/M procedure code
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
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.

Texas Medicaid & Healthcare Partnership
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