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December 2016 Texas Medicaid Provider Procedures Manual

Women’s Health Services Handbook : 3 Health and Human Services Commission (HHSC) Family Planning Program Services : 3.2 Services, Benefits, Limitations, and Prior Authorization : 3.2.1 Family Planning Annual Exams : FQHC Reimbursement for Family Planning Annual Exams
To receive the encounter rate for the annual family planning examination, FQHCs must use the most appropriate E/M procedure code for the complexity of service provided as indicated in the previous table in Subsection 3.2.1, “Family Planning Annual Exams” in this handbook and must use modifier FP.
The annual exam is allowed once per fiscal year, per client, per provider. Other family planning office or outpatient visits may be billed within the same year.
A new patient visit for the annual exam may be reimbursed once 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. The annual examination must be billed as an established patient visit if E/M services have been provided to the client within the last three years.
Reimbursement for services payable to an FQHC is based on an all-inclusive rate per visit.

Texas Medicaid & Healthcare Partnership
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