ModifiedAlliance HealthPolicy 1E-7

Family Planning Services

This policy governs coverage, eligibility, and billing for Medicaid family planning services in North Carolina for beneficiaries of childbearing age, including Traditional Medicaid and FP Medicaid (MAFDN-eligible). It affects providers delivering family planning consultations, exams, treatments, supplies, and associated services to eligible NC Medicaid beneficiaries.

Policy Summary

PayerAlliance Health

PolicyFamily Planning Services

Policy CodePolicy 1E-7

Change TypeMaterial coverage and coding updates (HPV vaccine, 12‑month contraceptive supply, rapid STI testing, billing clarifications)

Effective DateN/A

Next Review DateN/A

Key ActionVerify beneficiary eligibility and document required assessment dates and diagnoses (use primary contraception diagnosis Z30.* for MAFDN billing).

SourceLink

POLICY UPDATE CHANGES

Added coverage for HPV Gardasil 9 Vaccine and associated administration codes.

Changed requirement from a comprehensive annual exam prior to family planning services to an annual assessment.

Permits dispensing birth control pills up to a 12-month supply from a pharmacy.

Added point-of-care rapid HIV and syphilis coverage and clarified coverage of condoms and spermicides.

Clarified that providers serving MAFDN beneficiaries must bill using a primary diagnosis of contraception and provided the list of allowed ICD-10 contraception codes.

NC-onlyjurisdiction

Includes EPSDTspecial provision for <21

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12-monthmaximum contraceptive pill supply allowed

90651HPV vaccine added

6inter-periodic visits/year

6max STI antibiotic courses/yr

Coverage Criteria and Service Limits

Postoperative Sterilization Medication Coverage

Covered when ALL of the following are met:

The beneficiary is enrolled in Traditional Medicaid or Family Planning (FP) Medicaid and is eligible for sterilization procedures per policy Section 3.2.1 and Clinical Policy 1E-3.

Postoperative medications are prescribed for use following a covered sterilization procedure.

Prescriptions for postoperative sterilization medications include an appropriate sterilization diagnosis on the prescription and claim (per Attachment D requirements).

Medications are provided by prescription through the outpatient pharmacy program and are billed through the pharmacy benefit.

Medications are limited to those on the approved postoperative sterilization medication list (Attachment D), including the listed antibiotics, analgesics, and antiemetic agents.

Pharmacy providers shall not distribute DAW1 brand medically necessary dispense-as-written products if a generic is available.

The AED or AAD is not required on claims for approved postoperative sterilization medications when other program documentation requirements are met.

Billing Codes, Attachments and Frequency Rules

Claims and coding attachmentsmixed

See Attachment A

Claims-related information including ICD-10-CM, PCS, CPT/HCPCS codes, modifiers, billing units, place of service, co-payments, and reimbursement details listed in Attachment A.

FP Medicaid billing requirementsmixed

Attachment B

FP Medicaid (MAFDN-eligible) specific billing requirements, including inter-periodic visits, special services, laboratory tests, sterilization, ultrasounds.

Depression screening billing codesCPT | ICD-10Covered

96127	Brief emotional or behavioral assessment with scoring and documentation per standardized instrument
Z13.31	Encounter for depression screening
Z13.32	Encounter for screening for maternal depression

Referenced CPT/HCPCS codes mentioned in history/attachmentsmixed

J7296	HCPCS code added to HCPCS code table (document notes)
87661	CPT code for NAAT Trichomonas screening (added)
87563	CPT code for diagnostic Mycoplasma Genitalium testing (added)
82120	CPT code for amines screening for vaginitis (added)
87220	CPT code for KOH test (added)
87806	HIV screening code added as covered MAFDN service
58661	CPT code added (document notes)
87623	CPT code replacement noted in history
87624	CPT code replacement noted in history
87625	CPT code replacement noted in history

ICD-10 and selected CPT/HCPCS codes referenced in attachmentsmixed

Z30.011	ICD-10 contraception code (listed in policy)
Z30.42	ICD-10 contraception code (listed in policy)
Z30.012	ICD-10 contraception code (listed in policy)
Z30.430	ICD-10 contraception code (listed in policy)
90651	HPV vaccine Gardasil 9
90460	Vaccine administration (added)
90471	Vaccine administration (added)
A4267	HCPCS crosswalk to J7300 (listed)
A4268	HCPCS crosswalk to J7301 (listed)
J1050	HCPCS crosswalk to J7307 (listed)

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1/2

Covered office visit CPT codes (telehealth eligible)CPTCovered

99211	Office visit code (telehealth-eligible as listed)
99212	Office visit code (telehealth-eligible as listed)
99213	Office visit code (telehealth-eligible as listed)
99214	Office visit code (telehealth-eligible as listed)
99215	Office visit code (telehealth-eligible as listed)

Visit and contraceptive HCPCS/CPT codes (partial list in window)mixedCovered

99211	Office/visit code (listed among telehealth-eligible and inter-periodic visit codes)
99212	Office/visit code
99213	Office/visit code
99214	Office/visit code
99215	Office/visit code
99241	Office/visit code (telehealth eligible)
99242	Office/visit code (telehealth eligible)
99243	Office/visit code (telehealth eligible)
99244	Office/visit code (telehealth eligible)
99245	Office/visit code (telehealth eligible)

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Laboratory/Pap and pregnancy test codesCPTCovered

88141	Pap test (listed mapping to 88155)
88142	Pap test (listed mapping to 88164)
88143	Pap test (listed mapping to 88165)
88147	Pap test (listed mapping to 88166)
88148	Pap test (listed mapping to 88167)
88150	Pap test (listed mapping to 88174)
88152	Pap test (listed mapping to 88175)
81025	Pregnancy test
84702	Pregnancy test
84703	Pregnancy test

Comprehensive preventive medicine evaluation codesCPTCovered

99383	Comprehensive Preventive Medicine Evaluation codes (pediatric/adult series mapping)
99384	Comprehensive Preventive Medicine Evaluation code
99385	Comprehensive Preventive Medicine Evaluation code
99386	Comprehensive Preventive Medicine Evaluation code
99387	Comprehensive Preventive Medicine Evaluation code
99393	Comprehensive Preventive Medicine Evaluation mapping
99394	Comprehensive Preventive Medicine Evaluation mapping
99395	Comprehensive Preventive Medicine Evaluation mapping
99396	Comprehensive Preventive Medicine Evaluation mapping
99397	Comprehensive Preventive Medicine Evaluation mapping

Annual assessment and inter-periodic visit codesCPTCovered

99202	Annual Assessment / Inter-periodic visit mapping
99203	Annual Assessment / Inter-periodic visit mapping
99204	Annual Assessment / Inter-periodic visit mapping
99205	Annual Assessment / Inter-periodic visit mapping

Allowed Revenue Codes for institutional billingRevenue

RC0250	Revenue code (listed among allowed revenue codes for unlisted procedures)
RC0251	Revenue code
RC0252	Revenue code
RC0254	Revenue code
RC0255	Revenue code
RC0258	Revenue code
RC0259	Revenue code
RC0270	Revenue code
RC0271	Revenue code
RC0272	Revenue code

Laboratory and Pap/Pregnancy codesCPT | mixedCovered

81025	Pregnancy test
86689	HIV Screening (listed mapping to 87534)
88141	Pap Test (series includes 88141-88155 etc.)

HIV/Hepatitis screening codesCPT | mixedCovered

87534	HIV Screening (mapped)
86704	Hepatitis B Screening
87520	Hepatitis C Screening

Vaccine administration and diagnosisCPT | ICD-10Covered

90651	Gardasil 9 HPV vaccine
90460	Vaccine administration with counseling (≤18 years)
90471	Vaccine administration without counseling or >18 years
Z23	Encounter for immunization (ICD-10-CM)

STI testing and POC codesCPTCovered

86780	Point of care testing (Treponema listed mapping to 86703)
87590	Gonorrhea testing
87210	BV/Trichomonas/other misc microbiology codes

IUD complication procedureCPTCovered

58562

Surgical hysteroscopy with removal of impacted foreign body (used for embedded IUD removal)

Other screening/procedure codesCPT | Revenue

17000	Other Screenings or Procedures = 87071
54050	Other Screenings or Procedures = 93000

STI Medication Listmixed

N/A	Medication list for STIs — no billing or procedure codes provided in this attachment.

Postoperative Sterilization Medication List (policy)mixed

N/A	Postoperative sterilization medication policy statement — no specific codes listed.

Medications enumeratedmixed

N/A	Enumerated antibiotics, analgesics, and antiemetic agents for sterilization procedures (specific NDCs/CPTs not listed).

Repeat Pap test window

Repeat Pap test windowOne repeat Pap test allowed if initial specimen has insufficient cells; repeat must be performed within 180 calendar days of the first Pap test.

Pap test annual allowanceOne Pap test per 365 calendar days (CLIA-certified labs) during an annual assessment, comprehensive preventive medicine evaluation, or any inter-periodic visit.

Applicable visits for Pap testing

Provider Billing, Documentation and Authorization Requirements

Prior Authorization

EPSDT & prior authorization guidance

If a service requires prior approval, EPSDT (beneficiaries under 21) does NOT remove the prior approval requirement. Providers must follow NCTracks prior approval processes and the EPSDT guidance on the Medicaid website.

Refer to NCTracks Provider Claims and Billing Assistance Guide: https://www.nctracks.nc.gov/content/public/providers/providermanuals.html
Refer to EPSDT provider page: https://medicaid.ncdhhs.gov/

Billing Rule

Claims and prior authorization

Claims must be submitted according to NCTracks, Medicaid bulletins, fee schedules, and NC Medicaid clinical coverage policies. Providers must follow the NCTracks Provider Claims and Billing Assistance Guide and applicable Medicaid provider manuals.

Policy Background and Scope

Background: Family Planning Medicaid services are provided to eligible beneficiaries of childbearing age to temporarily or permanently prevent or delay pregnancy and to reduce unintended pregnancies. Covered services include consultation, examination, provider-prescribed treatment, laboratory testing, and FDA-approved family planning supplies and devices.

Key Definitions and Terms

Traditional Medicaid Family Planning

DefinitionTraditional Medicaid family planning services include consultation, examination, treatment prescribed by authorized clinicians, laboratory examinations and tests, and FDA-approved family planning supplies and devices to prevent conception.

Included services examplesServices encompass provider-prescribed treatment, laboratory testing, and FDA-approved supplies/devices for contraception.

Provider typesServices may be furnished by physicians, nurse midwives, physician assistants, nurse practitioners, or pharmacists per state protocol or under physician supervision.

FP Medicaid

FP Medicaid scopeFP Medicaid provides limited family planning and family planning-related services to beneficiaries with MAFDN eligibility.

Referral for non-family planning needs

Policy Summary

PayerAlliance Health

PolicyFamily Planning Services

Policy CodePolicy 1E-7

Change TypeMaterial coverage and coding updates (HPV vaccine, 12‑month contraceptive supply, rapid STI testing, billing clarifications)

Effective DateN/A

Next Review DateN/A

Key ActionVerify beneficiary eligibility and document required assessment dates and diagnoses (use primary contraception diagnosis Z30.* for MAFDN billing).

SourceLink

On This Page

Pap testing may be performed during annual assessment, comprehensive preventive medicine evaluation, or any of the six inter-periodic visits allowed under FP Medicaid.

Comprehensive Metabolic Panel frequency

CMP frequencyComprehensive Metabolic Panel may be billed once every three consecutive months in conjunction with an annual assessment, comprehensive preventive medicine evaluation, or an inter-periodic visit.

Context for billing CMPCMP billing must be in conjunction with an allowed FP visit (annual/comprehensive or one of six inter-periodic visits).

Venipuncture guidanceProviders billing for venipuncture must follow Clinical Policy 1S-3 Laboratory Services; venipuncture collection allowed to provider who extracted specimen only when sent to independent lab and no office testing is done.

Pap test repeat window

Repeat Pap timing requirementIf a Pap test requires repeat due to insufficient cells, the repeat Pap test must be performed within 180 calendar days of the first Pap test.

Annual Pap allowanceCLIA-certified laboratories may bill one Pap test per 365 calendar days during an annual assessment, comprehensive preventive medicine evaluation, or inter-periodic visit.

Eligible visit typesRepeat Pap tests may be performed during annual assessment, comprehensive preventive medicine evaluation, or any of the six inter-periodic visits under FP Medicaid.

Lab and treatment frequency

Urinalysis and blood count frequencyProviders are allowed one urinalysis and one blood count procedure code per 365 calendar days in conjunction with an annual assessment or comprehensive preventive medicine evaluation.

STI antibiotic course limitFP Medicaid allows up to six courses of STI antibiotic treatments from the policy's approved list per 365 calendar days; all approved antibiotics must include the appropriate ICD-10-CM on the prescription.

STI and screening visit contextPregnancy tests, STI, and HIV screening can be performed during an annual assessment, comprehensive preventive medicine evaluation, or any of the six inter-periodic visits.

Comply with NCTracks Provider Claims and Billing Assistance Guide and Medicaid bulletins for specific coverage and reimbursement.
All applicable federal, state and local laws and regulations (including HIPAA) apply.

Billing Rule

Outpatient surgical services limitation

For FP Medicaid beneficiaries, outpatient hospital surgical procedures requiring outpatient registration are limited to sterilization, IUD removal, or ultrasound for IUD-related complications (including missing strings). Ambulatory Surgical Centers are only applicable for sterilization procedures.

Inpatient hospital billing is not applicable for FP Medicaid beneficiaries.
Allowed outpatient hospital surgical procedures: sterilization, IUD removal, ultrasound for IUD complications.

Billing Rule

Contraceptive prescriptions identifiers

Pharmacy claims for approved contraceptive supplies and devices do not require the Annual Assessment Date (AAD) or Comprehensive Preventive Medicine Evaluation Date (AED). Family Planning program drugs have a family planning indicator on the drug file; DAW1 (brand medically necessary) should not be dispensed when a generic is available.

AED/AAD not required on claims for approved contraceptive supplies and devices.
Beneficiaries may receive up to a 12-month supply of birth control pills.
Do not dispense DAW1 when a generic is available.

Denial Risk

Beneficiary may be ineligible for service

A beneficiary may be ineligible for services due to service restrictions tied to their Medicaid eligibility category; providers must verify eligibility at each visit.

Verify each beneficiary's Medicaid eligibility at time of service.
Services may be denied if the beneficiary's eligibility category does not cover the service.

Denial Risk

General denial triggers

Services will be denied when the beneficiary does not meet eligibility (Section 2.0), does not meet clinical criteria (Section 3.0), the service duplicates another provider's service, or the service is experimental/investigational or part of a clinical trial.

Denial triggers include: ineligible beneficiary, failure to meet policy criteria, duplicate services, experimental/investigational services or clinical trial participation.

Billing Rule

Primary diagnosis requirement

All Family Planning Medicaid claims must use a primary diagnosis related to contraception. Failure to bill with an appropriate primary diagnosis may result in claim denials.

Primary diagnosis for MAFDN beneficiaries must reflect contraception (see listed ICD-10-CM Z30.* and related codes).
All family planning claim forms must include a family planning-related primary diagnosis.

Billing Rule

Unlisted procedure billing requirement

When billing unlisted procedures or services, follow the current CPT and HCPCS instructions for unlisted procedure reporting and include the required special report. For institutional UB claims, include an appropriate revenue code and a procedure code on the line item; absence of a procedure code or a procedure not covered under Family Planning Services will result in denial.

Follow CPT/HCPCS instructions for unlisted procedures and submit special reports as required.
For UB claims, bill an appropriate revenue code and include a procedure code on the line item; otherwise the line item will be denied.

Documentation Required

Required claim identifiers

The Annual Assessment Date (AAD) or Comprehensive Preventive Medicine Evaluation Date (AED) must be documented (month, day, year) on all claims for an annual assessment or comprehensive preventive medicine evaluation and on most related claims. Exceptions are pregnancy tests and prescriptions for approved contraceptive supplies/devices and certain sterilization-related prescriptions and services.

Include AED/AAD on claims for annual assessments, comprehensive evaluations, and most laboratory procedures (except pregnancy tests).
AED/AAD not required on prescriptions for approved contraceptive supplies/devices, postoperative sterilization medications, and certain sterilization ancillary services.

Documentation Required

Coding and documentation specificity

Report ICD-10-CM and PCS codes to the highest level of specificity in effect at the time of service. Use the current ICD-10 edition and Procedural Coding System; code selection must support medical necessity.

Report ICD-10-CM and PCS to the highest level of specificity.
Use the current code edition in effect at time of service.

Documentation Required

Ultrasound and IUD documentation

When an ultrasound is performed to evaluate IUD placement or related complications, document the reason for the ultrasound in the health record. Ultrasound is not intended for routine post-insertion checks. If IUD is expelled, a replacement may be reinserted without waiting period; embedded IUDs may require hysteroscopic removal (CPT 58562).

Document clinical reason for ultrasound when checking IUD placement.
Ultrasounds are allowed in-office or outpatient for missing strings or malposition; not for routine checking.
Use CPT 58562 for surgical hysteroscopy with removal of impacted foreign body when removing an embedded IUD.

Documentation Required

Diagnosis code for Mycoplasma testing

Providers must report an appropriate ICD-10-CM diagnosis code on claims for Mycoplasma Genitalium diagnostic testing when provided for urethritis, cervicitis, or pelvic inflammatory disease during allowable visits.

Mycoplasma Genitalium testing allowed during annual assessment, comprehensive preventive medicine evaluation, or inter-periodic visits for diagnoses of urethritis, cervicitis, and PID.
An appropriate ICD-10-CM diagnosis code is required on the claim.

Note

Coverage requires individualized, medically necessary selection

Coverage requires that any procedure, product, or service be individualized, medically necessary, safe, and the least costly equally effective option. Providers should select treatments specific to the beneficiary's symptoms/diagnosis and not in excess of needs.

Service must be individualized, specific, consistent with symptoms or confirmed diagnosis, and not in excess of the beneficiary's needs.
Service must be safe and no equally effective, more conservative, or less costly treatment available statewide.
Services must not be primarily for convenience of beneficiary or provider.

Beneficiaries needing non-family planning services must be referred to primary care or a safety net provider.

Eligibility noteFP Medicaid coverage is limited compared with Traditional Medicaid and is tied to MAFDN eligibility.

Family Planning Services

TermFamily Planning Services — services provided to eligible beneficiaries for contraception, STI screening/treatment, laboratory services, LARC insertion/removal, condoms/spermicides, contraceptive injections, HPV vaccination, depression screening, and covered sterilization procedures.

Service examplesIncludes diaphragm fitting, oral contraceptives per standing order, emergency contraception, IUD/implant insertion and removal, and select ultrasounds for malpositioned IUDs or missing strings.

Program requirementServices must adhere to 42 CFR §441.20 ensuring voluntary, non-coercive choice of family planning method.

Annual Assessment

Annual AssessmentAn office visit assessment (Annual Assessment) required prior to rendering family planning services; distinct from a comprehensive preventive medicine exam and may substitute for it within a 365-day period.

Documentation requirementThe Annual Assessment Date (AAD) or Comprehensive Preventive Medicine Evaluation Date (AED) with month, day, and year must be documented on claims except for pregnancy tests and certain contraceptive prescriptions and postoperative sterilization medications.

Billing guidanceWhen billing an annual assessment in lieu of a comprehensive preventive medicine evaluation, append the SC modifier and document that any same-day separately billable service was separately identifiable.

Comprehensive Preventive Medicine Exam

DefinitionComprehensive Preventive Medicine Exam — a full preventive medicine evaluation using current AMA CPT definitions; may be offered if beneficiary has not had a comprehensive evaluation in prior 365 days.

Interaction with Annual AssessmentIf a beneficiary had a comprehensive preventive medicine evaluation or postpartum exam in the prior 365 days, another comprehensive evaluation is not required before family planning services.

Billing codesComprehensive preventive medicine evaluations are billed using the current AMA CPT preventive medicine codes (see attachment for code list).

Z30.09

Z30.09 usageZ30.09 — Encounter for other general counseling and advice on contraception; used when beneficiary declines family planning services but reproductive health or contraceptive counseling occurred during the visit.

Billing consequenceWhen Z30.09 is billed because beneficiary declines FP services, the beneficiary is informed they are no longer eligible for FP Medicaid and should be referred for other medical concerns.

Claim documentationThe Annual Assessment Date or AED must still be documented when applicable; exceptions apply for pregnancy tests and certain prescriptions.

Inter-periodic visit

Inter-periodic visit allowanceInter-periodic visit — one of up to six visits permitted per 365 calendar days under the FP Medicaid program during which screenings, testing, and certain treatments may be provided.

Permitted services at inter-periodic visitsInter-periodic visits may include contraceptive evaluation, prescription renewal/change, STI/HIV screening and treatment, behavioral health follow-up, vaccine administration, and laboratory testing.

Counting visitsEach in-person or telehealth encounter counts as one of the six allowed inter-periodic visits per 365 days.

Gardasil 9

Gardasil 9 coverageGardasil 9 (HPV vaccine) is covered under FP Medicaid; CPT code 90651 must be used for Gardasil 9.

Administration codesVaccine administration CPT codes 90460 (with counseling ≤18 years) and 90471 (without counseling or >18 years) may be billed as appropriate.

Diagnosis coding for vaccineICD-10-CM code Z23 (Encounter for immunization) must be billed in addition to a family planning diagnosis on the claim for HPV vaccine.

Other Sexually Transmitted Infections

Approved STI antibiotic optionsAttachment C lists recommended antibiotic options for other STIs including azithromycin, doxycycline, erythromycin, and fluoroquinolones (levofloxacin, ofloxacin, moxifloxacin, gatifloxacin).

Other STI agentsAttachment C also lists agents for candidiasis, trichomoniasis, bacterial vaginosis, and pediculosis (e.g., metronidazole, tinidazole, fluconazole, permethrin).

Prescription requirementAll STI antibiotic prescriptions must include an appropriate ICD-10-CM diagnosis; AED/AAD is not required on STI prescriptions.

Postoperative sterilization medications

Coverage mechanismPostoperative sterilization medications are provided by prescription through the Outpatient Pharmacy drug program.

Prescription requirementAll prescriptions for postoperative sterilization medications must contain a sterilization diagnosis to be provided under this program.

Medication typesAttachment D enumerates antibiotics, analgesics, and antiemetics for sterilization procedures (specific agents and strengths listed in attachments).