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December 2016 Texas Medicaid Provider Procedures Manual

Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook : 2 Medicaid Title XIX Family Planning Services : 2.2 Services, Benefits, Limitations, and Prior Authorization : 2.2.1 Family Planning Annual Exams

2.2.1
An annual family planning exam consists of a comprehensive health history and physical examination, which includes the following:
Family planning providers must bill the most appropriate evaluation and management (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 family planning 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 with modifier FP and a family planning 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 with modifier FP and a family planning diagnosis code
* The established patient procedure code will be denied if a new patient procedure code has been billed in the same year.
An annual family planning examination (billed with modifier FP) will not be reimbursed when submitted with the same date of service as a surgical procedure or an additional E/M visit.
If another condition requiring an E/M office visit beyond the required components for the annual examination 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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