Table of Contents Previous Next

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 : 3.2.2 Family Planning Office or Outpatient Visits : FQHC Reimbursement for Family Planning Office or Outpatient Visits
To receive the encounter rate for a general family planning visit, FQHCs must use the most appropriate E/M procedure code for the complexity of service provided as indicated previously in the tables in Subsection 2.5.3, “National Drug Code” in this handbook.
FQHCs may be reimbursed for three family planning encounters per client, per year regardless of the reason for the encounter. The three encounters may include any combination of general family planning encounters, an annual family planning examination, or procedure code J7297, J7298, J7300, J7301, J7303, J7304, J7307, or S4993.
The new patient procedure codes will be limited to one new patient E/M procedure code 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.
A general family planning office or outpatient visit (billed without 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.
Refer to:
Section 4, “Federally Qualified Health Center (FQHC)” in the Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for more information about FQHC services.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.