ࡱ> c bjbj ]ffĜa 6 6 {{{{{`_# Pc,,...00 0bbbbbbb$ehv)b{0s0s0"00)b{{.. c===0{.{.b=0b==MO.mQ3*Na c0PcNi{4i(O@Oi{P00=00000)b)bw9N000Pc0000i0000000006 A: This Clinical Services Benefits Grid includes the codes for procedures, medications and contraceptive supplies that are reimbursable under the Family Planning, Access, Care and Treatment (Family PACT) Program. For codes for the management of complications1 that may arise from the use of a contraceptive method, refer to the Benefits: Family Planning section in this manual. Family Planning ServicesICD-10-CM CodeDescriptionProceduresLaboratory *SuppliesMedicationsZ30.012Encounter for prescription of emergency contraception81025: Urine pregnancy testJ3490U5: Ulipristal acetate (ECP) J3490U6: Levonorgestrel (ECP)Z30.09Encounter for general counseling and advice on contraception (33)81025: Urine pregnancy test (32)Z30.011 Z30.41Initial prescription, contraceptive pills Surveillance, contraceptive pills99000: Handling and/or conveyance of blood specimen to unaffiliated lab 81025: Urine pregnancy test A4267: Male condom A4268: Internal condom Spermicides: A4269U1: Gel, jelly, cream, or foam A4269U2: Suppository A4269U3: Vaginal film A4269U4: Sponge S5199: LubricantS4993: Oral Contraceptives S5000/S5001: Estradiol (requires additional ICD-10-CM code N92.1) J3490U5: Ulipristal acetate (ECP) J3490U6: Levonorgestrel (ECP)Z30.015 Z30.44 Z30.016 Z30.45Initial prescription, vaginal ring Surveillance, vaginal ring Initial prescription, transdermal patch Surveillance, transdermal patchJ7304: Contraceptive transdermal patch J7303: Contraceptive vaginal ring S5000/S5001: Estradiol (requires additional ICD-10-CM code N92.1) J3490U5: Ulipristal acetate (ECP) J3490U6: Levonorgestrel (ECP)(1) Complication services require a Treatment Authorization Request (TAR), unless stated otherwise. Refer to the Benefits: Family Planning section in this manual. (32) When clinically indicated to rule out pregnancy prior to initiation of a contraceptive method, but no contraceptive method is initiated during the visit or currently used by the client. Pregnancy confirmation for women not seeking family planning services is not reimbursable under Z30.09. Refer to the Benefits: Family Planning section in this manual for more information. (33) Z30.09, for this encounter, is used for counseling on contraceptive methods (other than sterilization) but no contraceptive method is initiated during the visit or currently used by the client. Refer to the Benefits: Family Planning section in this manual for more information. * These tests may be indicated on a case-by-case basis to determine whether a client can safely use a particular contraceptive method and are not intended to be routinely ordered for all clients. Family Planning ServicesICD-10-CM CodeDescriptionProceduresLaboratory *SuppliesMedicationsZ30.013 Z30.42Initial prescription, injectable contraceptive Surveillance, injectable contraceptive99000: Handling and/or conveyance of blood specimen to unaffiliated lab81025: Urine pregnancy test A4267: Male condom A4268: Internal condom Spermicides: A4269U1: Gel, jelly, cream, or foam A4269U2: Suppository A4269U3: Vaginal film A4269U4: Sponge S5199: LubricantJ3490U8: Medroxy-progesterone acetate for contraception S5000/S5001: Estradiol (requires additional ICD-10-CM code N92.1) J3490U5: Ulipristal acetate (ECP) J3490U6: Levonorgestrel (ECP)* These tests may be indicated on a case-by-case basis to determine whether a client can safely use a particular contraceptive method and are not intended to be routinely ordered for all clients. Family Planning ServicesICD-10-CM CodeDescriptionProceduresLaboratory *SuppliesMedicationsZ30.017 Z30.46Initial prescription, subdermal implant Surveillance, subdermal implant11976: Removal 11981: Insertion 99000: Handling and/or conveyance of blood specimen to unaffiliated lab 73060: X-ray humerus (34) 76882: Ultrasound, limited, joint or other nonvascular extremity structure(s) (34)81025: Urine pregnancy test11976UA: Removal A4267: Male condom A4268: Internal condom Spermicides: A4269U1: Gel, cream, jelly, or foam A4269U2: Suppository A4269U3: Vaginal film A4269U4: Sponge S5199: LubricantJ7307: Etonogestrel implant S5000/S5001: Estradiol (requires ICD-10-CM code N92.1) J3490U5: Ulipristal acetate (ECP) J3490U6: Levonorgestrel (ECP)(34) Restricted to use for evaluating impalpable subdermal contraceptive implant only. Refer to Benefits: Family Planning section in this manual for more information. * These tests may be indicated on a case-by-case basis to determine whether a client can safely use a particular contraceptive method and are not intended to be routinely ordered for all clients. Family Planning Services ICD-10-CM CodeDescriptionProceduresLaboratory *SuppliesMedicationsZ30.430 Z30.431 Z30.432 Z30.433Insertion, intrauterine contraceptive device Routine checking, intrauterine contraceptive device Removal of intrauterine contraceptive device Removal and reinsertion of intrauterine contraceptive device58300: Insertion 58301: Removal 74018: X-ray abdomen, 1 view (6) 76830: Transvag US (6) 76857: US pelvic limited or F/U (6) 99000: Handling and/or conveyance of blood specimen to unaffiliated lab81025: Urine pregnancy test 85013, 85014: Hematocrit 85018: Hemoglobin 58300UA: Insertion 58301UA: Removal A4267: Male condom A4268: Internal condom Spermicides: A4269U1: gel, jelly, cream or foam A4269U2: Suppository A4269U3: Vaginal film A4269U4: Sponge S5199: LubricantJ7297: Levonorgestrel IU (liletta), 52 mg J7298: Levonorgestrel IU (mirena), 52 mg J7300: Intrauterine copper contraceptive J7301: Levonorgestrel IU (skyla), 13.5 mg J3490U5: Ulipristal acetate (ECP) J3490U6: Levonorgestrel (ECP) J7296: Levonorgestrel IU (kyleena) 19.5 mg S5000/S5001: Estradiol (requires ICD-10-CM code N92.1)(6) Restricted to use for evaluating missing IUC strings only. Refer to the Benefits: Family Planning section in this manual for more information. * These tests may be indicated on a case-by-case basis to determine whether a client can safely use a particular contraceptive method and are not intended to be routinely ordered for all clients. Family Planning Services ICD-10-CM CodeDescriptionProceduresLaboratory *SuppliesMedicationsZ30.018 Z30.49 Initial prescription of other contraceptives (male or female barrier and/or spermicide) Surveillance of other contraceptives (male or female barriers and/or spermicide)57170: Diaphragm/ cervical cap fitting 99000: Handling and/or conveyance of blood specimen to unaffiliated lab81025: Urine pregnancy testA4261: Cervical cap A4266: Diaphragm A4267: Male condom A4268: Internal condom Spermicides: A4269U1: Gel, jelly, cream, or foam A4269U2: Suppository A4269U3: Vaginal film A4269U4: Sponge S5199: LubricantJ3490U5: Ulipristal acetate (ECP) J3490U6: Levonorgestrel (ECP) Z30.02Counseling and instruction in natural family planning to avoid pregnancy81025: Urine pregnancy testBBT (26) J3490U5: Ulipristal acetate (ECP) J3490U6: Levonorgestrel (ECP)Z31.61Procreative counseling and advice using natural family planning (34)81025: Urine pregnancy testBBT (26)(26) Available for pharmacy dispensing only. (34) Encounters are limited to two occurrences in a 12-month period per client, per provider. Refer to Benefits: Family Planning section in this manual for more information. * These tests may be indicated on a case-by-case basis to determine whether a client can safely use a particular contraceptive method and are not intended to be routinely ordered for all clients. Family Planning Services ICD-10-CM CodeDescriptionProceduresLaboratory *SuppliesMedicationsZ30.09 Z01.812 (28)Encounter general counseling and advice on contraception (sterilization) (35) Encounter for pre-procedural lab exam (female sterilization)  99000: Handling and/or conveyance of blood specimen to unaffiliated lab81025: Urine pregnancy test Preoperative tests: 81000: UA dipstick w/microscopy 81001: UA automated w/microscopy 81002: UA dipstick w/out microscopy 81003: UA automated w/out microscopy 85013: Spun Hct 85014: Hct 85018: Hemoglobin 85025: Auto CBC w/auto diff. WBC 85027: Auto CBC w/out differential 85002: Bleeding time (27) 85610: Prothrombin time (27) 85730: thromboplastin time (27) (27) TAR required. Refer to the Benefits: Family Planning section in this manual for more information. (28) Use with ICD-10-CM code Z30.09. Refer to the Benefits: Family Planning section in this manual for more information. (35) Z30.09, for this encounter, is for sterilization counseling and advice, including consent and pre-operative evaluation, if indicated. Refer to Permanent Contraception in the Benefits: Family Planning section in this manual for more information. * These tests may be indicated on a case-by-case basis to determine whether a client can safely use a particular contraceptive method and are not intended to be routinely ordered for all clients. Family Planning Services ICD-10-CM CodeDescriptionProceduresLaboratory *SuppliesMedicationsZ01.818 (28)Encounter for other pre-procedural exam (female sterilization) 71046: Chest X-ray (7) 93000: ECG (7) 93307: Echocardiography (7) (27) Z30.2Encounter for sterilization (female)58565: Hysteroscopic surgical placement of micro-insert(s) 58600: Mini lap TL 58615: Mini lap TL with clip 58661: Laparoscopy with removal of adnexal structures 58670: Laparoscopic fulguration 58671: Laparoscopic sterilization with ring or clip 58700: Salpingectomy, complete or partial 58555: Hysteroscopy, diagnostic (29)88302: Surgical path. (two specimens) A4264 50/52: Intratubal occlusion device (micro-inserts) 58565UA/UB: Hysteroscopic surg supplies 58600UA/UB: Mini-Lap TL 58615UA/UB: Mini-Lap with clip 58661UA/UB: Laparoscopy with removal of adnexal structures 58670UA/UB: Laparoscopic fulguration 58700UA/UB: Salpingectomy, complete or partial 58671UA/UB: Laparoscopic sterilization with ring or clip(7) As medically indicated for preoperative evaluation of a pre-existing medical condition or required by outpatient facility. (27) TAR required. Refer to the Benefits: Family Planning section in this manual for more information. (28) Use with ICD-10-CM code Z30.09. Refer to the Benefits: Family Planning section in this manual for more information. (29) Used when CPT code 58565 is attempted and placement fails. Refer to the Benefits: Family Planning section in this manual for more information. * These tests may be indicated on a case-by-case basis to determine whether a client can safely use a particular contraceptive method and are not intended to be routinely ordered for all clients. Family Planning ServicesICD-10-CM CodeDescriptionProceduresLaboratory *SuppliesMedicationsZ98.51Tubal ligation status74740: Hysterosalpingo graphy (30) 58340: Catheterization and introduction of saline or contrast material for saline infusion sonohystero graphy [SIS] or hysterosalpingo graphy (31) A4267: Male condom A4268: Internal condom Spermicides: A4269U1: Gel, jelly, cream or foam A4269U2: Suppository A4269U3: Vaginal film A4269U4: Sponge S5199: LubricantJ3490U5: Ulipristal acetate (ECP) J3490U6: Levonorgestrel (ECP) (30) Restricted to confirm tubal occlusion 12 weeks after CPT code 58565. If occlusion is not confirmed, CPT code 74740 may be repeated at 24 weeks post-op. Use with CPT code 58340. Refer to the Benefits: Family Planning section in this manual for more information. (31) CPT code 58340 is used with 74740. Refer to the Benefits: Family Planning section in this manual for more information. * These tests may be indicated on a case-by-case basis to determine whether a client can safely use a particular contraceptive method and are not intended to be routinely ordered for all clients. Family Planning ServicesICD-10-CM CodeDescriptionProceduresLaboratory *SuppliesMedicationsZ01.812 (28)Encounter for pre-procedural lab exam (male sterilization) 99000: Handling and/or conveyance of blood specimen to unaffiliated lab Preoperative tests: 81000: UA dipstick w/microscopy 81001: UA automated w/microscopy 81002: UA dipstick w/out microscopy 81003: UA automated w/out microscopy 85013: Spun Hct 85014: Hct 85018: Hemoglobin 85025: Auto CBC w/auto diff. WBC 85027: Auto CBC w/out differential(28) Use with ICD-10-CM code Z30.09. Refer to the Benefits: Family Planning section in this manual for more information. * These tests may be indicated on a case-by-case basis to determine whether a client can safely use a particular contraceptive method and are not intended to be routinely ordered for all clients. Family Planning ServicesICD-10-CM CodeDescriptionProceduresLaboratory *SuppliesMedicationsZ30.2Encounter for sterilization (male)55250: Vasectomy88302: Surgical path (two specimens)55250UA/UB: VasectomyZ98.52Vasectomy statusA4267: Male condom A4268: Internal condom Spermicides: A4269U1: Gel, jelly, cream or foam A4269U2: Suppository A4269U3: Vaginal film A4269U4: Sponge S5199: LubricantPost vasectomy semen analysis is included in the global fee for vasectomy. * These tests may be indicated on a case-by-case basis to determine whether a client can safely use a particular contraceptive method and are not intended to be routinely ordered for all clients. Reproductive Health These services may be provided as clinically indicated. These Screening Tests services are not reimbursable for Z30.012, Z30.09 and Z31.61. For more information, refer to the Benefits: Family Planning section in this manual. Reproductive Health Screening TestsCPT CodeDescriptionReflex Testing (based on a positive screening test result)Restrictions86592VDRL, RPR86780 TP-confirmatory test; if positive, 86593 is required86593 Syphilis test, non-treponemal antibody; quantitative 86701HIV-1 antibody86689 HIV confirmatory test (e.g. Western Blot) OR 86701 and 86702 differentiation assay AND 87535 HIV - NAAT (if differentiation assay results are negative or indeterminate)86689 limited to HIV antibody86702HIV-2 antibody86703HIV-1 and HIV-2 antibodies, single result87389HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result87806HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies87491 *NAAT - ChlamydiaNoneRefer to the Chlamydia Trachomatis (CT) and Neisseria gonorrhoeae (GC) screening guidelines87591 *NAAT - GonorrheaNone * CT and GC screening tests for females 25 years of age and older and males of all ages require an additional ICD-10-CM code. Females under 25 years of age may require an additional ICD-10-CM code. For additional information, refer to the Benefits: Family Planning section in this manual. Family Planning-Related The following laboratory tests are covered when clinically indicated Services: Cervical and provided as part of, or as a follow-up to, a family planning visit. Cancer Screening These tests must be ordered in conjunction with a family planning visit. These tests are billed with the appropriate family planning ICD-10-CM diagnosis code and may require an additional diagnosis code. Providers may refer to the Laboratory Services section in this manual. Cervical CytologyAdditional InformationCPT CodeDescriptionRefer to the Benefits: Family Planning-Related Services section in this manual for additional restrictions and claim requirements.88142LBC, manual screen88143LBC, manual screen and rescreen88147Smear, automated screen88148Smear, automated screen, manual re-screen88164Smear, Bethesda, manual screen88165 88167Smear, Bethesda, manual screen, re-screen Smear, Bethesda, manual screen, computer re-screen88174LBC, automated screen 88175LBC, automated screen, manual re-screenHuman Papillomavirus (HPV) TestingAdditional InformationCPT CodeDescriptionRefer to the Benefits: Family Planning-Related Services section in this manual for additional information and claim requirements.87624 87625HPV. high-risk types HPV, 16/18 genotype Family Planning-Related Treatment or diagnostic testing of specified sexually transmitted Services: Management of infections (STIs) may be provided as clinically indicated. For services Sexually Transmitted to manage a complication of family planning-related treatment, refer to Infections (STIs) the Benefits: Family Planning-Related Services section in this manual. (11) Family Planning-Related Services (9)ICD-10-CM CodeDescriptionProceduresLaboratorySuppliesMedications (8)Z20.2 Use Z20.2 for diagnosis and treatment of an asymptomatic partner exposed to active case of chlamydia, gonorrhea, syphilis, or trichomoniasis (M/F)   A56.01 A56.09 A56.3 A56.4 N34.2 N45.3 N72 N89.8 N94.10 N94.11 N94.12 N94.19 N94.89 R30.0 R30.9 Z20.2Chlamydia CT cystitis and urethritis (M/F) Other chlamydial infection lower of genitourinary tract (F) CT anus/rectum (M/F) CT pharynx (M/F) Presumptive Dx Other urethritis (M) Epididymo-orchitis (M) Inflammatory disease of cervix uteri (F) Other specified non-inflammatory disorders of vagina (F) Unspecified dyspareunia (F) Superficial (introital) dyspareunia (F) Deep dyspareunia (F) Other specified dyspareunia (F) Other conditions associated with female genital organs (F) Dysuria (M/F) Painful micturition, unspecified (M/F) STI (CT)-exposed partner (M/F)None87205: Gram stain " symptomatic males only 87491: CT, amplified probe techniqueNoneAzithromycin Doxycycline (8) Only dosage regimens included in current CDC STD Treatment Guidelines or California STD Treatment Guidelines may be used. See www.cdph.ca.gov for more information. See the Pharmacy Formulary and Clinic Formulary sections in this manual for additional information about regimen, formulation and coverage limits. (9) An additional ICD-10-CM code is required for any treatment or diagnostic testing beyond screening tests. (11) Services to evaluate and manage a complication of treating a family planning-related service require an additional ICD-10-CM code. A TAR is required, unless stated otherwise. Refer to the Benefits: Family Planning-Related Services section in this manual. Family Planning-Related Services (9)ICD-10-CM CodeDescriptionProceduresLaboratorySuppliesMedications (8) A54.01 A54.5 A54.6 A54.22 A54.03 N34.2 N45.3 N72 N89.8 N94.10 N94.11 N94.12 N94.19 N94.89 R30.0 R30.9 Z20.2Gonorrhea GC cystitis and urethritis, unspecified (M/F) GC pharyngitis (M/F) GC anus/rectum (M/F) GC prostatitis (M) GC cervicitis, unspecified (F) Presumptive Dx Other urethritis (M) Epididymo-orchitis (M) Inflammatory disease of cervix uteri (F) Other specified non-inflammatory disorders of vagina (F) Unspecified dyspareunia (F) Superficial (introital) dyspareunia (F) Deep dyspareunia (F) Other specified dyspareunia (F) Other conditions associated with female genital organs (F) Dysuria (M/F) Painful micturition, unspecified (M/F) STI (GC)-exposed partner (M/F)None87205: Gram stain symptomatic males only 87591: GC, amplified probe techniqueNoneAzithromycin Cefixime Ceftriaxone Doxycycline A60.01 A60.04 N48.5 N76.6Herpes (genital only) Herpes penis HSV Vulvovaginitis Presumptive Dx Ulcer of penis Ulceration of vulvaNoneAdditional Restrictions Apply (12) 87252: HSV culture 87255: HSV culture 87273: HSV DFA Type IINoneAcyclovir(8) Only dosage regimens included in current CDC STD Treatment Guidelines or California STD Treatment Guidelines may be used. See www.cdph.ca.gov for more information. See the Pharmacy Formulary and Clinic Formulary sections in this manual for additional information about regimen, formulation and coverage limits. (9) An additional ICD-10-CM code is required for any treatment or diagnostic testing beyond screening tests. (11) Services to evaluate and manage a complication of treating a family planning-related service require an additional ICD-10-CM code. A TAR is required, unless stated otherwise. Refer to the Benefits: Family Planning-Related Services section in this manual. (12) Only as necessary to evaluate genital ulcers of unconfirmed etiology; payable for 616.50 (F) or 608.89 (M) only. Viral culture limited to Herpes simplex only. Reflex typing is not covered. Family Planning-Related Services (9)ICD-10-CM CodeDescriptionProceduresLaboratorySuppliesMedications (8) N70.03 N70.93 N94.10 N94.11 N94.12 N94.19 N94.89PID (uncomplicated outpatient only) Acute salpingitis and oophoritis Salpingitis and oophoritis, unspecified Unspecified dyspareunia (F) Superficial (introital) dyspareunia (F) Deep dyspareunia (F) Other specified dyspareunia (F) Other conditions associated with female genital organs (F)99000: Handling and/or conveyance of blood specimen for transfer to lab85025: CBC/diff 85651: ESR 85652: ESR 87491: CT, amplified probe technique 87591: GC, amplified probe techniqueNoneAzithromycin Ceftriaxone injection Cefoxitin injection Doxycycline Metronidazole Ofloxacin Probenecid A51.0 A51.31 A51.39 A51.5 A52.8 A53.0 N48.5 N76.6 Z20.2Syphilis Primary genital (M/F) Condyloma latum (M/F) Other, secondary (M/F) Early, latent (M/F) Late, latent (M/F) Latent, unspecified (M/F) Presumptive Dx Ulcer of penis Ulceration of vulva STI (Syphilis) exposed partner99000: Handling and/or conveyance of blood specimen for transfer to lab86593: Syphilis test, non-treponemal antibody; quantitative (15) NonePenicillin G benzathine long acting injection Doxycycline A59.01 A59.03 N76.0 N34.2 Z20.2Trichomoniasis Trichomonal vulvo-vaginitis Trich. cystitis and urethritis Acute vaginitis Presumptive Dx Other urethritis (M) STI (Trichomoniasis) exposed partner (M/F)None83986: pH (females only) 87210: Wet mount 87661: NAAT T. vaginalis (females only) 87808: T. vaginalis immunoassay (females only) Q0111: Wet mountNoneMetronidazole Tinidazole (16)(8) Only dosage regimens included in current CDC STD Treatment Guidelines or California STD Treatment Guidelines may be used. See www.cdph.ca.gov for more information. See the Pharmacy Formulary and Clinic Formulary sections in this manual for additional information about regimen, formulation and coverage limits. (9) An additional ICD-10-CM code is required for any treatment or diagnostic testing beyond screening tests. (11) Services to evaluate and manage a complication of treating a family planning-related service require an additional ICD-10-CM code. A TAR is required, unless stated otherwise. Refer to the Benefits: Family Planning-Related Services section in this manual. (12) Only as necessary to evaluate genital ulcers of unconfirmed etiology; payable for 616.50 (F) or 608.89 (M) only. Viral culture limited to Herpes simplex only. Reflex typing is not covered. (15) Only as necessary to confirm response to syphilis treatment; should not be ordered with presumptive diagnosis codes. (16) Only as a treatment for vaginal trichomoniasis if treatment failure or adverse effects (but not allergy) with prior use of Metronidazole Family Planning-Related Services (9)ICD-10-CM CodeDescriptionProceduresLaboratorySuppliesMedications (8) B37.3 N76.0Vulvovaginitis Candidiasis of vulva and vagina Acute vaginitisNone83986: pH (females only) 87210: Wet mount Q0111 Wet mountNoneClotrimazole Fluconazole Miconazole Terconazole (27) Clindamycin Metronidazole A63.0 B08.1 B07.9Warts (genital only) Anogenital (venereal) warts (M/F) Molluscum (M/F) Viral wart, unspecified (M/F)54050: Destruction of penile lesion; chemical (14) 54056: Destruction of penile lesion; cryo (14) 54100: Biopsy of penis (17) 56501: Destruction vulvar lesion (14) 57061: Destruction vaginal lesion (14) 56605: Biopsy, vulva (17)88305: Surgical path for males (17) 88305: Surgical path for females (17)54050UA 54056UA 54100UA 56501UA 57061UA 56605UAImiquimod Podofilox(8) Only dosage regimens included in current CDC STD Treatment Guidelines or California STD Treatment Guidelines may be used. See www.cdph.ca.gov for more information. See the Pharmacy Formulary and Clinic Formulary sections in this manual for additional information about regimen, formulation and coverage limits. (9) An additional ICD-10-CM code is required for any treatment or diagnostic testing beyond screening tests. (11) Services to evaluate and manage a complication of treating a family planning-related service require an additional ICD-10-CM code. A TAR is required, unless stated otherwise. Refer to the Benefits: Family Planning-Related Services section in this manual. (14) Supply charges for these procedures include the TCA/BCA, liquid nitrogen or podophyllin used. (17) Only as necessary to confirm vulvar, vaginal or genital warts in a wart treatment candidate. (27) Restricted to pharmacy dispensing only; for use after treatment failure with other anti-fungals, TAR required. Family Planning-Related Treatment or diagnostic tests for the management of urinary tract Services: Management of infection (UTI) are covered when provided as part of, or as a follow-up Urinary Tract Infection (UTI) to, a family planning visit where the UTI was identified or diagnosed. An additional ICD-10-CM code is required as noted below. These benefits are for female clients only. Family Planning-Related ServicesICD-10-CM CodeDescriptionProceduresLaboratorySuppliesMedications  N30.00 N30.01 R31.0 R30.0 R30.9 R35.0 R10.30UTI Acute cystitis without hematuria Acute cystitis with hematuria Gross hematuria Dysuria Painful micturition, unspecified Frequency of micturition Lower abdominal pain, unspecifiedNone81000: UA dipstick w/microscopy 81001: UA automated w/microscopy 81002: UA dipstick w/out microscopy 81003: UA automated w/out microscopy 81005: UA (qualitative) 81015: Urine microscopyNoneCephalexin Ciprofloxacin Nitrofurantoin TMP/SMX Family Planning-Related Treatment and management of specified cervical abnormalities are Services: Management covered when provided as part of, or as a follow-up to, a family of Cervical Abnormalities planning visit, where the cervical abnormality was identified or diagnosed. An additional ICD-10-CM code is required for treatment and diagnostic services for the management of women with cervical abnormalities. Colposcopy is limited to women e"15 of age. For services to manage a complication of family planning-related treatment, refer to the Benefits: Family Planning-Related Services section in this manual. Family Planning-Related ServicesICD-10-CM CodeDescriptionProceduresLaboratorySuppliesMedicationsR87.610 R87.619Abnormal result, cytologic smear of cervixNone88141: Pap requiring physician interpretationR87.610 R87.611 R87.612 R87.613 R87.810 N88.0ASC-US ASC-H LGSIL HGSIL Cervical high risk HPV DNA test positive Presumptive Dx. Leukoplakia, cervix57452: Colposcopy 57454: Colpo with biopsy & ECC 57455: Colpo with biopsy 57456: Colpo with ECC87624: HPV, high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (18) 88305: Surgical pathology57452UA 57454UA 57455UA 57456UA NoneR87.619Unspecified abnormal cytological findings in specimen from cervix uteri 57452: Colposcopy 57454: Colpo with biopsy & ECC 57455: Colpo with biopsy 57456: Colpo with ECC 58110: Endometrial biopsy w/colpo (19)87624: HPV, high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (18) 88305: Surgical pathology57452UA 57454UA 57455UA 57456UA 58110UA None(18) Coverage for HPV testing and co-testing coverage are based on the American Society of Colposcopy and Cervical Pathology (ASCCP) 2012 Updated Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Test and Cancer Precursors. DNA amplified probe HPV (high risk only) is covered for women ages e"21 years, once per 365 days, any provider, following the HPV Testing and Co-testing Guidelines table in this section. For additional information, refer to the Benefits: Family Planning-Related Services section in this manual. (19) Endometrial biopsy is covered only with AGC (atypical glandular cells) cytology result and any of the following: Atypical endometrial cells on AGC cytology result; or Complaints of abnormal vaginal bleeding pattern suspicious for endometrial hyperplasia or cancer; or Recipient is e"36 years of age. Family Planning-Related ServicesICD-10-CM CodeDescriptionProceduresLaboratorySuppliesMedications N87.0 N87.1 D06.9CIN 1 (biopsy) CIN 2 (biopsy) CIN 3 (biopsy)57452: Colposcopy 57454: Colpo with biopsy & ECC 57455: Colpo with biopsy 57456: Colpo with ECC 57511: Cryocautery of cervix (22) 57460: LEEP (22)87624: HPV, high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (18) 88305: Surgical pathology 88307: Surgical pathology (21)57452UA 57454UA 57455UA 57456UA 57511UA 57460UA R87.618Other abnormal cytological findings58100: Endometrial biopsy (20)88305: Surgical pathology58100UA(18) Coverage for HPV testing and co-testing coverage are based on the American Society of Colposcopy and Cervical Pathology (ASCCP) 2012 Updated Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Test and Cancer Precursors. DNA amplified probe HPV (high risk only) is covered for women ages e"21 years, once per 365 days, any provider, following the HPV Testing and Co-testing Guidelines table in this section. For additional information, refer to the Benefits: Family Planning-Related Services section in this manual. (20) Endometrial biopsy restricted to ages e"40 years with a finding of endometrial cells on Pap and a recent history of menstrual irregularity. (21) Restricted to biopsy specimens collected by LEEP procedure. (22) Restricted to biopsy proven CIN 2 and CIN 3, or persistent CIN 1 lesions of greater than 12 months, ages e"15 years. See ASCCP Guidelines 2006. TREATMENT AND DISPENSING GUIDELINES FOR CLINIcians Family Planning-Related Conditions Drug RegimensCONDITIONMEDICATIONDOSAGE SIZEREGIMENS *FILL FREQ DAYSNOTESCLINIC CODEBacterial Vaginosis Metronidazole250mg/500mg tabs500mg PO BID X 7 days15Recommended regimenS5000/ S50010.75% vaginal gel5g PV QHS X 5 days30Clindamycin2% cream5g PV X 7 days30Recommended regimen150mg capsules300mg PO BID X 7 days15Alternative regimen100mg ovules100mg PV QHS X 3 days30ChlamydiaAzithromycin500mg tabs/1gm pkt1gm PO X 12 per rolling 30 daysRecommended regimenQ0144Doxycycline100mg tabs100mg PO BID X 7daysRecommended regimenS5000/ S5001EpididymitisCeftriaxone AND Doxycycline250mg injection250mg IM X 1"Recommended regimenJ0696100mg tabs100mg PO BID X 10 days2 per rolling 30 daysS5000/ S5001External Genital WartsImiquimod5% creamQHS 3/wks up to 16 weeks30S5000/ S5001Podofilox0.5% solution/gelBID 3 days/wk followed by 4 days no treatment up to 4 weeks30Genital HerpesAcyclovir200mg tabs200mg PO 5/day X 5 or 10 days30Primary S5000/ S5001400mg tabs400mg PO TID X 5 or 10 days30400mg tabs 800mg tabs400 PO TID X 5 days 800mg PO BID X 5 days OR 800mg PO TID x 2 days30Recurrent herpes400mg tabs400mg PO BID30Suppression of recurrent herpes* CDC, Sexually Transmitted Diseases Treatment Guidelines 2015, MMWR 2015:64. Family Planning-Related Conditions Drug RegimensCONDITIONMEDICATIONDOSAGE SIZEREGIMENS *FILL FREQ DAYSNOTESCLINIC CODEGonorrhea (see Note 4)Ceftriaxone 250mg injection250mg IM X 115Recommended regimen (see Note 1)J0696PLUS Azithromycin 1gm1gm PO X 12 per rolling 30 daysQ0144Cefixime400mg tabs/caps400 mg PO X 115Alternative regimen (see Note 1)S5000/ S5001PLUS Azithromycin OR1gm1gm PO X 12 per rolling 30 daysQ0144Doxycycline100mg tabs100mg PO BID X 7 daysS5000/ S5001 Ceftriaxone OR250mg injection250mg IM X 1"J0696 PID Cefoxitin WITH Probenecid1gm injection2gm IM X 1"Recommended regimen (see Note 2)J0694500mg tabs1gm PO X 130PLUS Doxycycline100mg tabs100mg PO BID X 14 days2 per rolling 30 daysS5000/ S5001 With or without Metronidazole250/500mg tabs500mg PO BID X 14 days30Ceftriaxone PLUS Azithromycin250mg injection250mg IM X 12 per rolling 30 days Alternative regimen (see Note 2) With or without Metronidazole1gm 250/500mg tabs1gm PO once a week for 2 weeks 500mg PO BID X 14 daysOfloxacin200/400mg tabs400mg PO BID X 14 days30 (see Note 3) Alternative regimen (see Note 2) S5000/ S5001With or without Metronidazole1gm 250/500mg tabs500mg PO BID X 14 days30S5000/ S5001* CDC, Sexually Transmitted Diseases Treatment Guidelines 2015, MMWR 2015:64. Note 1: For patients with significant anaphylaxis-type allergies to penicillin or allergies to cephalosporins, treat with gentamicin 240 mg IM (onsite dispensing only with code J1580; requires a TAR) with azithromycin 2 gm PO X 1 (see Benefits: Family Planning-Related Services, Pharmacy Formulary and Clinic Formulary sections of this manual.) Note 2: Addition of metronidazole is recommended if concomitant bacterial vaginosis and to improve anaerobic bacteria coverage. Note 3: Only if unable to receive an injectable cephalosporin regimen and if at low risk for GC infection. If this regimen is given, a GC test must be done. If positive for GC, the patient must be treated with an antibiotic that covers quinolone-resistant GC. Note 4: Dual treatment with drug regimen effective against chlamydia is recommended regardless of chlamydia test results (see chlamydia treatment regimen on preceding page). Family Planning-Related Conditions Drug RegimensCONDITIONMEDICATIONDOSAGE SIZEREGIMENS *FILL FREQ DAYSNOTESCLINIC CODERecurrent/ Persistent NGU or Cervicitis Moxifloxacin400mg tabs400mg PO QD x 7 days (see Note 5)SyphilisPenicillin G benzathine1.2mil units/2 ml 2.4mil units/4 ml2.4mil units IM X 1Primary, secondary, early latent syphilisJ0561Doxycycline100mg tabs100mg PO BID X 2 weeks30Alternative regimenS5000/ S5001Penicillin G benzathine1.2mil units/2 ml 2.4mil units/4 ml2.4mil units IM q wk X 3 dosesLate latent, unknown duration syphilisJ0561Doxycycline100mg tabs100mg PO BID X 4 weeks30Alternative regimenS5000/ S5001Tricho-moniasisMetronidazole500mg tabs2gm PO X 115Recommended regimenS5000/ S5001500mg PO BID X 7 days15Alternative regimenTinidazole250/500mg tabs2gm PO X 115(see Note 6)Urinary Tract Infection SMX/TMP DS800/160mg tabs800/160mg PO BID X 3 days15Recommended regimenS5000/ S5001SMX/TMP400/80mg tabs400/80mg 2 PO BID X 3 days15Alternative regimenCiprofloxacin250mg tabs250mg PO BID X 3 days15Alternative regimenCephalexin500mg caps500mg PO BID X 7-10 days15Recommended regimen250mg caps250mg PO QID X 7-10 days15Alternative regimenNitrofurantoin50mg/100mg caps/tabs100mg PO BID x 5 days15Recommended regimen (see Note 7)* CDC, Sexually Transmitted Diseases Treatment Guidelines 2015, MMWR 2015:64. American Academy of Family Physicians, American Family Physician 2005; 72:451-6,458. Note 5: For persistent and recurrent cervicitis and nongonococcal urethritis that has not responded to treatment with doxycycline or azithromycin, treat with moxifloxacin (pharmacy dispensing only, requires a TAR). See Benefits: Family Planning-Related Services and Pharmacy and Clinic Formulary sections of this manual. Note 6: Only for trichomoniasis in case of treatment failure or adverse effects (not allergy) with prior use of metronidazole. Note 7: For pharmacy dispensing only. Family Planning-Related Conditions Drug RegimensCONDITIONMEDICATIONDOSAGE SIZEREGIMENS *FILL FREQ DAYSNOTESCLINIC CODE Vaginal Candidiasis Clotrimazole2% cream QHS for 3 days30 S5000/ S5001 NA1% cream QHS for 7 days30Fluconazole150mg tabletSingle dose PO30Miconazole4% cream QHS for 3 days302% cream QHS for 7 days30200mg vaginal suppository QHS for 3 days30100mg vaginal suppository QHS for 7 days30Terconazole +80mg suppository QHS for 3 days30Reserve for use in complicated cases of Vaginal Candidiasis. Restricted to Pharmacy dispensing only; for use after treatment failure with other anti-fungals, TAR required.0.8% cream QHS for 3 days300.4%cream QHS for 7 days30* CDC, Sexually Transmitted Diseases Treatment Guidelines 2015, MMWR 2015:64. Oil-based products may weaken latex condoms and diaphragms. + Only available for pharmacy dispensing with approved TAR. Family PACT Contraceptives SuppliesContraceptive SuppliesBilling UnitMaximum Quantity OnsiteEarliest refill: OnsiteRefill Frequency Limit PharmacyClinic CodeCondoms, maleeach(see Note 8)15 daysMale Condoms up to 36 units per 27 days A4267Spermicidal Gel/Jelly/Foam/Creamper gramAll other contraceptive supplies are limited to 3 refills in any 75-day periodA4269U1 A4269U2 A4269U3 A4269U4 S5199Spermicidal SuppositoryeachSpermicidal Vaginal FilmeachSpermicidal Contraceptive SpongeeachLubricantper gramCondoms, internaleachUp to 12 units per claimUp to 24 units in a 90-day periodInternal Condoms no more than 12 units per claim and no more than two claims in a 90-day periodA4268Basal Body ThermometereachN/AN/A1 per yearNAContraceptive DiaphragmeachN/AN/ALimited to 1 diaphragm per yearNAContraceptive Cervical Cap (Fem Cap)eachN/AN/ALimited to 2 cervical caps per yearNANote 8: There is a $14.99 claim limit for contraceptive supplies dispensed onsite on a single date of service. Refer to the Drugs: Onsite Dispensing Price Guide section for the Family PACT rate per unit. Family PACT ContraceptivesContraceptivesDosage SizeMaximum Quantity: OnsiteEarliest refill: OnsiteMaximum Quantity: PharmacyEarliest refill: PharmacyClinic CodeOral Contraceptives1 cycle18 cycles(see Note 9)18 cycles(see Note 9)S4993Contraceptive Patch1 patch52 patches(see Note 9)52 patches(see Note 9)J7304Contraceptive Vaginal Ring1 ring13 rings(see Note 9)13 rings(see Note 9)J7303Medroxyprogesterone Acetate1 injection1 injection80 daysN/AN/AJ3490U8Intrauterine copper contraceptive 1 IUC1 IUC(see Note 10)1 IUCJ7300Etonogestrel Contraceptive Implant1 implant1 implant(see Note 10)N/AN/AJ7307Levonorgestrel IU (liletta), 52 mg1 IUC1 IUC(see Note 10)N/AN/AJ7297Levonorgestrel IU (mirena), 52 mg 1 IUC1 IUC(see Note 10)N/AN/AJ7298Levonorgestrel IU (skyla), 13.5 mg1 IUC1 IUC(see Note 10)N/AN/AJ7301Levonorgestrel IU (kyleena) 19.5 mg1 IUC1 IUC(see Note 10)N/AN/AJ7296Emergency contraception1 pack (2 tablets)1 packet/ event combined maximum of 6 packs/yearAs medically indicated up to limit1 pack/ event combined maximum of 6 packs/yearAs medically indicated up to limitJ3490U6Levonorgestrel 1.5 mg1 pack (1 tablet)J3490U6Ulipristal Acetate 30 mg1 pack (1 tablet)J3490U5Note 9: The dispensing of up to the maximum quantity is intended for clients on continuous cycle. 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A TAR is required for the third supply of up to 12 months of the same product requested within a year. Note 10: Providers must document the medical necessity for billing repeat implant or IUC/IUD placement of the same device within the devices duration of use, as noted by the label, in the Remarks field (Box 80)/Additional Claim Information field (Box 19) of the claim.     familypact18  PAGE 2 ben grid Benefits Grid  PAGE 1 Benefits Grid Family PACT 139 April 2019 ben grid  PAGE 2 ben grid  PAGE 2 Benefits Grid Family PACT 75 December 2013 Benefits Grid Family PACT 139 April 2019 ben grid  PAGE 4 ben grid  PAGE 3 Benefits Grid Family PACT 62 November 2012 Benefits Grid Family PACT 139 April 2019 ben grid  PAGE 4 ben grid  PAGE 4 Benefits Grid Family PACT 75 December 2013 Benefits Grid Family PACT 139 April 2019 ben grid  PAGE 5 Benefits Grid Family PACT 139 April 2019 ben grid  PAGE 6 ben grid  PAGE 6 Benefits Grid Family PACT 75 December 2013 Benefits Grid Family PACT 96 September 2015 ben grid  PAGE 7 Benefits Grid Family PACT 124 January 2018 ben grid  PAGE 8 Benefits Grid Family PACT 139 April 2019 familypact18 6 ben grid  PAGE 9 Benefits Grid Family PACT 96 September 2015 ben grid  PAGE 10 Benefits Grid Family PACT 139 April 2019 ben grid  PAGE 20 ben grid  PAGE 11 Benefits Grid Family PACT 75 December 2013 Benefits Grid Family PACT 137 February 2019 ben grid  PAGE 12 Benefits Grid Family PACT 138 March 2019 ben grid  PAGE 20 ben grid  PAGE 13 Benefits Grid Family PACT 75 December 2013 Benefits Grid Family PACT 132 September 2018 ben grid  PAGE 14 Benefits Grid Family PACT 132 September 2018 ben grid  PAGE 12 ben grid  PAGE 15 Benefits Grid Family PACT 75 December 2013 Benefits Grid Family PACT 131 August 2018 ben grid  PAGE 12 ben grid  PAGE 16 Benefits Grid Family PACT ___ ____ 2013 Benefits Grid Family PACT 132 September 2018 ben grid  PAGE 14 ben grid  PAGE 17 Benefits Grid Family PACT 75 December 2013 Benefits Grid Family PACT 116 May 2017 ben grid  PAGE 14 ben grid  PAGE 18 Benefits Grid Family PACT ___ ____ 2013 Benefits Grid Family PACT 116 May 2017 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Benefits Grid (ben grid) Cruze, Hannah(       Oh+'0  ( 4 T ` l x     Benefits Grid (ben grid)  LB pgs. 1-13 (10.18.07) new section (ben grid) MT pgs. 7-8 (11.06.07) LB pgs. 5-6 (12.11.07) LB pgs. 1-4, 9-10 (05.08.08) LB pgs. 9-10 (06.05.08) MR pgs 1-8 (07.08.08) JT pgs. 7-10 (08.06.08) JT pgs. 1-6, 9-10, 13 (09.08.08) JT pgs. 5-6 (09.18.08) corrections JT pgs. 7-8 (11.05.08) JT pgs. 13 (03.05.09) LB pgs. 5-8, 11-13 (12.08.09) JT pgs. 1-2, 5-6 (01.11.10) JT pgs. 7-8 (02.05.10) JT pgs. 9-12 (05.06.10) JT pgs. 7-8, 11-12 (06.29.10) SA pgs. all (07.15.10) odd/even pages fixes JT pgs. 1-6, 13 (08.06.10) JT pgs. 1, 2, 4, 5, 8, 10, 11-13 (10.06.10) JT pg. 5 (12.07.10) JT pgs. all (02.04.11) No content changes, reformat properties JT pg. 13 (03.31.11) SA pgs. 2, 6, 10 (05.05.11) CF pgs. 1-5 (06.03.11) SA pgs. 7, 11-15 (07.11.11) SA pg. 12 (07.13.11) added edits per Lilian de los Santos JT pg. 12 (12.15.11) 2011 HCPCS JT pg. 12 (06.06.12) JT pgs. 1-5 (11.13.12) JT pgs. 11-13 (02.05.13) JT pgs. 1-15, 16-20 new (12.12.13) JT pgs. 1-20, 21-23 new (03.12.14) JT pgs. 4, 23 (06.12.14) JT pgs. 6, 11, 13, 14 (08.11.14) JT pg. 11, 17-20 (10.06.14) JT pgs. 2, 23 (11.07.14) JT pgs. 13, 23 (06.05.15) WC pgs. 1-5, 7, 10, 13-18 (07.07.15) AA pgs. 1-18, 22 (09.03.15) JT pgs. 4, 23 (10.06.15) JT pgs. 1, 5, 7, 10, 13, 14 (11.03.15) AbR pgs. 1-3 (03.07.16) MiR pgs. 13-15, 19-23 (05.11.16) JT pg. 11 (06.06.16) MiR pg. 12 (07.06.16) BB pgs. 4, 11, 23 (09.07.16) MiR pg. 11 (10.05.16) JT pgs. 1, 3, 5 (11.09.16) MiR pgs. 13, 14, 16, 20, 21, 23 (01.11.17) JT pg. 23 (04.12.17) MiR pgs. 13-23, 24 new (05.12.17) MiR pgs. 4, 5, 24 (06.07.17) SE pgs. 4, 7, 12, 13, 24 (09.12.17) 2017 HCPCS MiR pg. 21 (12.14.17) HC pgs. 3, 4, 7, 24 (01.10.18) 2018 HCPCS LSa pgs. 14, 15, 24 (04.06.18) HC pgs. 13-16, 24 (08.08.18) HC pgs. 11, 13, 14, 16 (09.05.18) MiR pg. 12 (11.06.18) updated from CPT-4 to CPT SE pg. 11 (02.12.19) HC pg. 12 (03.07.19) KW pgs. 1-5, 8, 10, 24 (04.04.19) HC pg. 24 (07.02.19) HC pg. 24 (11.13.19) HC pg. 7 (12.10.19) CPT Conversion; transparent edits, no policy/footer updates Normal.dotmCruze, Hannah10Microsoft Office Word@e@`LmE@&-%@Pe_ ՜.+,0 hp  CA-MMISPt Benefits Grid (ben grid) Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry Fm@Data  1TableM(iWordDocument ]SummaryInformation(DocumentSummaryInformation8MsoDataStore mmQJZMWTE4FBQ==2 mmItem  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q