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Family planning expansion benefit appendix to 5101 21 02.3 rev 10.13.11.xls

Covered Family Planning (FP) Family Planning-Related (FPR) Services These services must be billed with a family planning diagnosis code (V25.01-V25.9) Destruction of Lesions, Penis, Simple; Chemical Destruction of Lesions, Penis, Simple; Cryosurgery APPENDIX p(85319) pa(154063) d(347635) ra(298681) Covered Family Planning (FP) Family Planning-Related (FPR) Services These services must be billed with a family planning diagnosis code (V25.01-V25.9) Colposcopy of the cervix including upper/adjacent Vagina Examination & Biopsy (Colposcopy, with Biopsy Endocervical CurettageCauterization of Cervix (Cautery of Cervix; Electro or Covered Family Planning (FP) Family Planning-Related (FPR) Services These services must be billed with a family planning diagnosis code (V25.01-V25.9) Ultrasound bone density measurement (TC/26) Urinalysis Routine Wo.Microscopy, Nonauto Urinalysis Routine Wo Microscopy, Automat Immunoassay, For Analyte Not Ab, Qual/Semi Transaminase (SGOT); Aspartateamino (AST) Covered Family Planning (FP) Family Planning-Related (FPR) Services These services must be billed with a family planning diagnosis code (V25.01-V25.9) Ab; Herpes Simplex, Non-Specific Type Test Culture, Bac, An; Id, Ea Anaerobic Organism Covered Family Planning (FP) Family Planning-Related (FPR) Services These services must be billed with a family planning diagnosis code (V25.01-V25.9) Chlamydia Trachomatis Antigen Detection by DFA Chlamydia Trachomatis Antigen Detection by EIA Hepatitis B Surface Antigen Detection by EIA Hepatitis Be Antigen Detection by EIA Code Candida Detection by DNA, Amplified Probe Chlamydia Pneumoniae Detection by DNA, Dir. Prob Chlamydia Pneumoniae Detection by DNA, Amp. Pro Chlamydia Pneumoniae Detection by DNA, Quantif.
Chlamydia Trachomatis Detection by DNA, Dir. Probe Chlamydia Trachomatis Detection by DNA, Amp. Probe Chlamydia Trachomatis Detection by DNA, Quantif.
Gardnerella Vaginalis Detection by DNA, Direct Prob Gardnerella Vaginalis Detection by DNA, Amp. Probe Gardnerella Vaginalis Detection by DNA, Quantif.
Covered Family Planning (FP) Family Planning-Related (FPR) Services These services must be billed with a family planning diagnosis code (V25.01-V25.9) Herpes Simplex Detection by DNA, Direct Probe Herpes Simplex Detection by DNA, Amplified Probe Herpes Virus-6 Detection by DNA, Quantification Neisseria Gonorrhoeae, DNA Direct Probe Technique Infect Agent Detect by Nucleic Acid, NOS, Dir. Probe Infect Agent Detect by Nucleic Acid, NOS, Amp. Probe Infect Agent Detect by Nucleic Acid, NOS, Quantif.
Chlamydia Trachomatis Detection by Immunoassay Cytopath, Cerv/Vag Thin Layer Preparation Covered Family Planning (FP) Family Planning-Related (FPR) Services These services must be billed with a family planning diagnosis code (V25.01-V25.9) Cytopathology Smears, Cervical or Vaginal; Screening by Automated System Under Physician SupervisionCytopathology Smears, Cervical or Vaginal; Screening by Automated System Under Physician SupervisionCytopathology Smears, Cervical or Vaginal; Screening by Automated System with manual Re-screening Under Physician Supervision Cytopath C/V Index Add-OnCytopathology, Slides, Cervical or Vaginal (the Bethesda System); Manual Screening Under Physician SupervisionCytopathology with Manual Screening and Re-screening Under Physician SupervisionCytopathology with Manual Screening and Computer Assisted Re-screening Under Physician SupervisionCytopathology with Manual Screening and Computer Assisted Re-screening Using Cell Selection and Review Under Physician SupervisionCytopathology, Cervical or Vagina (Any Reporting System), Collected in Preservative Fluid, Automated Thin Layer Preparation, Screening by Automated System Under Physician SupervisionCytopathology, Cervical or Vagina (Any Reporting System), Collected in Preservative Fluid, Automated Thin Layer Preparation, Screening by Automated System and Manual Rescreening or Review, Under Physician Supervision Level II Surg Path Gross & Micro Exam Covered Family Planning (FP) Family Planning-Related (FPR) Services These services must be billed with a family planning diagnosis code (V25.01-V25.9) Level IV - Surgical Pathology, Gross and Microscopic ExaminationLevel V - Surgical Pathology, Gross and Microscopic Hepatitis B Immune Globulin, Intramuscular, 1ml Hepatitis A and Hepatitis B vaccine, adultHuman papilloma virus (HPV), types 6, 11, 16, 18, 3 HPV; types 16, 18 bivalent, 3 Dose Schedule1 Hepatitis B vaccine, Dialysis/Imm, 40 mcgTherapeutic, Prophylactic or Diagnostic Injection (specify material injected) Subcutaneous or Covered Family Planning (FP) Family Planning-Related (FPR) Services These services must be billed with a family planning diagnosis code (V25.01-V25.9) Preventive Counseling, Indiv., 30 Min.
Preventive Counseling, Indiv., 45 Min.
Preventive Counseling, Indiv., 60 Min.
Medroxyprogesterone Ace/Estradiol Cyp Inj,5mg/25mg Levonorgestrel-Releasing Intrauterine Contracep Sys Levonorgestrel Implant System (Including Supplies) Covered Family Planning (FP) Family Planning-Related (FPR) Services These services must be billed with a family planning diagnosis code (V25.01-V25.9) Annual Gynecological Exam, Established Patient Contraceptive Intrauterine Device, e.g. Progestacer T1015-UA, Clinic Visit/Encounter, All-inclusive

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