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Family Planning Services Program — Covered Services Chart

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A covered-services chart listing procedure codes, billing modifiers, provider types/specialties, place of service, fees, prior authorization status, unit limits, post-op day rules, and billing comments for the Pennsylvania Family Planning Services Program.

Policy Summary

PayerPennsylvania Insurance Department

PolicyFamily Planning Services Program — Covered Services Chart

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDec 30, 2025

Last ReviewDec 30, 2025

Next Review DateN/A

Key ActionWhen billing family planning services, include the FP modifier or ICD-10 diagnosis Z30.011–Z30.9 as indicated on each procedure row.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MultipleFP modifier required

15+Code rows shown

VariedFees listed

Limits notedFrequency limits

FP or Z30.xBilling requirement

Coverage Criteria and Per-Procedure Rules

Per-procedure coverage criteria rows (sampled)

Per-code coverage rows (examples below) provide the program stance and billing rules.

Code: 11976 — Removal, implantable contraceptive capsules; Coverage: covered; Fee: $118.05; Units: per procedure; Limits: 1 per 3 calendar years; Prior authorization: No; Post-op days: 0 days; Billing note: This provider type must bill with the FP modifier or with the ICD-10 DX Z30.011–Z30.9.

Code: 11981 — Insertion, drug-delivery implant; Coverage: covered; Fee: $776.00 (example); Units: per procedure; Limits: N/A; Prior authorization: No (AUR and PSR process may apply); Billing note: This provider type must bill with the ICD-10 DX Z30.011–Z30.9 or FP modifier as indicated.

Code: 11982 — Removal, non-biodegradable drug delivery implant; Coverage: covered; Fees: $126.75 to $776.00 depending on provider row; Units: per procedure; Limits/ frequency: once per day where specified; Prior authorization: No (AUR/PSR may apply in some rows); Billing note: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Code: 11983 — Removal with reinsertion, non-biodegradable drug delivery implant; Coverage: covered; Fee examples: $200.00, $382.51 (varies by provider type); Units: per procedure; Limits: N/A in some rows; Prior authorization: No (PSR may apply); Billing note: Bill with FP modifier or ICD-10 Z30.* as indicated.

Code: 58301 — Insertion/removal of intrauterine device (IUD); Coverage: covered; Fees: examples $174.03 (family planning provider rows) and $366.78 in other rows; Units: per procedure; Limits: 1 per 3 calendar years; Prior authorization: No, but AUR and PSR process applies in some entries; Post-op days: 0; Billing note: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Code: 55200 — Vasotomy/cannulization; Coverage: covered; Fee: varies by provider/specialty (examples shown across rows); Units: per procedure; Prior authorization: No, but AUR and PSR process may apply; Billing note: Must bill with ICD-10 Z30.011–Z30.9 or FP modifier as indicated.

Code: 55250 — Vasectomy (includes postoperative semen exam); Coverage: covered; Fee examples shown (e.g., $282.79, $417.84, $776.00 depending on row); Limits: once per lifetime (where indicated); Prior authorization: No or AUR/PSR as noted; Billing note: Bill with ICD-10 Z30.011–Z30.9 or FP modifier.

Coverage rows and constraints

Coverage table rows specify for each code: service description, provider type/group codes, billing modifier requirement, payment amount, pre/post authorization or review notes, frequency limits, and timeframes.

Code: 58301 — IUD insertion/removal; Payment examples: $174.03 (family planning provider rows) or $366.78 in other rows; Units: per procedure; Frequency: 1 per 3 calendar years; Prior auth/review: No, but AUR and PSR process applies in some entries; Billing: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Code: 58340 — Catheterization/sonohysterography or hysterosalpingography; Payment examples include $776.00; Units: per procedure; Frequency: once per day where noted; Prior auth/review: No, but AUR and PSR process applies; Billing: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Code: 58565 — Hysteroscopy with bilateral fallopian tube cannulation (placement of permanent implants); Payment examples: $776.00 or $405.57 depending on provider row; Units: per procedure; Limits: once per lifetime in some rows; Prior auth/review: No, but AUR/PSR process may apply; Billing: Bill with FP modifier or ICD-10 DX.

Code range: 58600–58671 — Sterilization procedures (ligation/occlusion/fulguration); Payments vary by code (examples shown in chart); Units: per procedure; Frequency/limits: varies by code (two per lifetime, once per lifetime, N/A); Prior auth/review: No, but AUR/PSR process applies for some provider types; Billing: Must bill with ICD-10 Z30.011–Z30.9 or FP modifier.

Code: 74740 — Hysterosalpingography, radiological supervision/interpretation; Payment: $26.50; Units: per procedure; Frequency: once per day; Prior auth: No; Billing: Must bill with FP modifier or ICD-10 DX.

Code: 81025 — Urine pregnancy test (visual); Payment: $10.76; Units: per test; Frequency: once per day; Prior auth: No; Billing: Must bill with FP modifier or ICD-10 DX.

Code: 84703 — hCG qualitative test; Payment: $10.26; Units: per test; Frequency: once per day; Prior auth: No; Billing: Must bill with FP modifier or ICD-10 DX.

Coverage criteria and billing rules (excerpt)

Codes listed are included in the Family Planning Services Program with specified allowed amounts, billing units, and required billing modifiers or diagnosis codes.

Code: 84703 — Gonadotropin, chorionic (hCG), qualitative; Allowed amount: $10.26; Unit: per test; Frequency: once per day; Billing requirement: FP modifier or ICD-10 DX Z30.011–Z30.9 where specified.

Code: 87521 — Infectious agent detection (Hepatitis C, amplified probe); Allowed amount: $38.21 (example from chart excerpts); Unit: per test; Frequency: once per day; Billing requirement: Bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Code: 87660 — Trichomonas vaginalis detection (direct probe); Allowed amount: $22.42; Unit: per test; Frequency: once per day; Billing requirement: Bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Codes: 99202–99205 (new patient E/M) — Per-visit billing; Allowed amounts listed (e.g., 99202 $92.07; 99205 $209.15); Frequency: once per day; Time-based selection thresholds apply (99202=15 min, 99205=60 min); Billing: Bill with FP modifier or ICD-10 DX where specified.

Visit rule: When using total time on date of encounter for E/M selection, required thresholds must be met or exceeded (examples: 99202=15 min; 99203≈30 min; 99204≈45 min; 99205=60 min).

Coverage and billing criteria (excerpt)

Coverage applies to listed CPT E/M and preventive CPT codes when billed according to program rules:

Requirement: Provider must bill with FP modifier or with the ICD-10 diagnosis Z30.011–Z30.9 where indicated in the chart.

Time-based E/M selection: Total time on the date of the encounter must meet or exceed specified minute thresholds for code selection (examples: 99205=60 min; 99212=10 min; 99213=20 min; 99214=30 min; 99215=40 min).

Frequency limits: E/M and preventive codes are subject to frequency constraints as listed (examples: 99211 limited to one per year; most E/M codes limited to once per day; preventive codes have annual combination limits).

Payment: Reimbursement amounts are listed per code in the chart and apply when billing rules (modifier/diagnosis, unit, frequency) are followed.

Coverage criteria for charted family planning services

Coverage and billing requirements for listed family planning services and supplies.

Sample codes and requirements: 99395/99396 (preventive E/M), A4264 (permanent implantable contraceptive device), J7296–J7301 (IUS/implant supplies), T1015 (clinic visit). Providers must bill with FP modifier or ICD-10 Z30.011–Z30.9 as indicated.

Frequency examples: 99401 once per lifetime; A4264 once per lifetime; A4266 two per 365 days; contraceptive supplies (A4267/A4268) 144 per 30 days where listed.

Reimbursement examples from chart: 99395 $110.60; 99396 $120.25; A4264 $1,300.00; J7296 (Kyleena) listed at program device pricing in chart.

Utilization review: AUR and PSR processes apply to select anesthesia or device rows; prior authorization status varies by code/provider row.

Per-code coverage entries (examples)

Coverage and billing requirements shown per procedure code include payment amounts, whether AUR/PSR applies, frequency/limits, and billing modifiers/diagnosis requirements.

Code: 11420 — Excision, benign lesion; Fee examples vary by provider/setting (e.g., $572.00 or $40.00); Units: per procedure; Frequency: per procedure, allowed twice per day in some rows; Post-op/follow-up interval: 10 days where specified; Billing: Bill with FP modifier or ICD-10 DX Z30.011–Z30.9 where indicated; AUR/PSR: No, but AUR and PSR process applies for some provider-type rows.

Per-code coverage criteria (excerpted rows)

Per-code coverage entries include allowed service descriptions, payment amounts, provider-type specifics, required billing diagnosis or modifier, frequency, and administrative review notes.

Code: 17110 — Destruction of benign lesions (up to 14 lesions); Payment examples across rows (e.g., $645.00 or $85.20 depending on provider type); Units: per procedure; Frequency: once per day where noted; Follow-up interval: 10 days in many rows; Billing: Must bill with FP modifier or ICD-10 Z30.011–Z30.9; AUR/PSR: may apply for some provider-type rows.

Code: 17111 — Destruction of benign lesions (15+ lesions); Payment examples include $776.00 or $105.29 depending on row; Units: per procedure; Frequency: once per day where noted; Billing: Must bill with FP modifier or ICD-10 Z30.* as indicated; AUR/PSR: may apply.

Code: 46900 / 46916 / 46917 — Destruction of anal lesions (chemical/electro/cryosurgery/laser); Payments and provider-type rows vary (examples shown); Units: per procedure; Frequency: once per day; Follow-up interval: 10 days where specified; Billing: Bill with FP modifier or ICD-10 family planning diagnosis; AUR/PSR status varies by row.

Procedure-level coverage rules (excerpt)

Coverage and billing guidance for listed CPT procedures in the Family Planning Services Program:

Billing diagnosis/modifier rule: Provider must bill listed procedure codes with the FP modifier or with ICD-10 diagnosis codes Z30.011–Z30.9 where indicated in the chart.

Payment amounts: Each procedure row includes a listed payment amount (examples in extract: 46924 $230.08; 54050 $129.69; 54055/54057/54065/56405 fees as shown).

Billing unit/frequency: Entries specify billing unit as 'per procedure' and commonly list 'once per day'; some entries indicate a 10-day follow-up or 90-day intervals as applicable.

Utilization review: Some codes note 'No, but AUR and PSR process' or reference PSR/AUR indicating possible administrative review for certain provider/code combinations.

Coverage nodes for this chart segment

Coverage and billing conditions shown for each CPT code include:

General rule: CPT code is covered when billed with the FP modifier or with ICD-10 DX Z30.011–Z30.9 where specified in the chart.

Unit/frequency: Unit is typically 'per procedure'; frequency is often 'once per day' unless otherwise noted; some codes show 0 days or a 10-day related interval.

PSR/AUR: Some procedures indicate PSR and/or AUR processes apply; many entries explicitly state 'No' for PSR while others note administrative review may occur.

Fee examples: Multiple fee values are listed per code in the chart segment (e.g., 56405 $93.81; 56420 $112.73; 56440 $225.08; 56501 $141.09; 56515 $249.18/$804.00; 56606 $37.30; 56820 $77.24; 56821 $105.72).

Procedure-specific coverage nodes

Per-procedure coverage details and billing instructions found in the chart excerpt:

Code: 56821 — Colposcopy of the vulva with biopsy(s); Coverage: covered; Allowed amount example: $105.72; Units: per procedure; Frequency: once per day; Post-op days: 0 days; Billing: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Code: 57061 — Destruction of vaginal lesion(s), simple; Coverage: covered; Allowed amounts shown (examples $607.00 and $120.58 depending on provider row); Units: per procedure; Frequency: once per day where noted; Administrative: No, but AUR and PSR process may apply in some rows; Billing: Bill with ICD-10 Z30.011–Z30.9 or FP modifier.

Code: 57100 — Destruction of vaginal lesion(s), extensive; Coverage: covered; Fees: examples $607.00 then $216.16 in other rows; Units: per procedure; Frequency and post-op intervals vary; Billing: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9; AUR/PSR may apply as noted.

Code: 57150 — Biopsy of vaginal mucosa, extensive; Coverage: covered; Allowed amount examples $27.05 (FP rows) or $70.00; Units: per procedure; Frequency: once per day; Follow-up interval: 0–10 days as shown; Billing: Bill with FP modifier or ICD-10 DX.

Code: 57421/57452/57460 — Colposcopy variants: Covered when billed per chart; Fees and allowed amounts vary by provider-type row (examples: 57421 $81.73 / $155.89; 57452 $155.89 / $114.64 / $584.00; 57460 $202.40–$776.00). Frequency: per procedure; some entries one per 90 days; Billing: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9; AUR/PSR may apply in some rows.

Select procedure coverage rows (excerpt)

Procedure-specific coverage rows include required billing modifiers/diagnoses, payment amounts, frequency limits, and administrative process notes.

Code: 57421 — Colposcopy entire vagina with biopsy(s); Coverage: covered; Payment examples: $81.73 and $155.89 depending on provider row; Frequency: per procedure; some rows list one per 90 days; Billing: Must bill with FP modifier or ICD-10 Z30.011–Z30.9; Administrative: PSR process referenced in some rows.

Code: 57452 — Colposcopy including upper/adjacent vagina with biopsy(s); Coverage: covered; Payments vary ($114.64–$584.00 shown); Frequency: per procedure; one per 90 days noted in some rows; Billing: Must bill with FP modifier or ICD-10 Z30.011–Z30.9; Administrative: AUR and PSR may apply.

Code: 57460 — Colposcopy with loop electrode biopsy(s); Coverage: covered; Payment examples vary (e.g., $202.40–$776.00); Units: per procedure; Frequency: once per day or N/A depending on row; Billing: Must bill with ICD-10 Z30.011–Z30.9 or FP modifier; Administrative: AUR/PSR process noted in some rows.

Example CPT entry: 57461

Coverage entries by CPT code include: payment amount, whether PSR/AUR applies, billing modifier/diagnosis requirement, frequency and day/interval limits.

Code: 57461 — Colposcopy with loop electrode conization; Payment examples: $776.00 (many rows) and $234.04 in some FP rows; Units: per procedure; Frequency: once per day or N/A as shown; PSR/AUR: PSR process applies in some provider-type rows; Billing: Must bill with ICD-10 DX Z30.011–Z30.9 or FP modifier.

Example CPT entry: 57522

Conization and excision procedures

Code: 57522 — Conization of cervix (loop electrode excision); Coverage: covered; Payment examples: $776.00 (general) and $217.95 when billed by FP provider rows; Units: per procedure; Frequency: once per day; Interval for repeat procedures: 90 days where specified; PSR/AUR: No or PSR process depending on provider-type row; Billing: Bill with FP modifier or ICD-10 DX Z30.011–Z30.9 as specified.

Example CPT entry: 57800

Dilation procedures

Code: 57800 — Dilation of cervical canal, instrumental; Coverage: covered; Payment examples: $817.00 in some rows and $60.09 in FP provider rows; Units: per procedure; Frequency: once per day; Post-op days: 0 days in many entries; Administrative: PSR process noted for some provider-type rows; Billing: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9 as applicable.

Per-code coverage entries (excerpt)

Per-procedure coverage entries include payment amount, whether AUR/PSR processes apply, frequency limits, and billing modifier or diagnosis requirements.

Code: 57800 — Dilation of cervical canal; Coverage: covered; Payment: ranges $60.09 to $817.00 depending on provider type; Frequency: per procedure; once per day; Billing: Bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Code: 58100 — Endometrial sampling (biopsy); Coverage: covered; Payment examples: $730.00 (some rows) and $108.89 (FP rows); Prior auth/review: No, but AUR and PSR process applies in some rows; Units: per procedure; Frequency: once per day where shown; Billing: Bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Code: 58110 — Endometrial sampling in conjunction with colposcopy; Coverage: covered; Payment: $32.05 in chart; Units: per procedure; Frequency: once per day; Billing: Bill with FP modifier or ICD-10 DX.

Code: 58562 — Hysteroscopy with removal of impacted foreign body; Coverage: covered; Payment: ranges $359.51 to $776.00 depending on provider type; AUR/PSR: No, but AUR and PSR process applies for some provider types; Billing: Bill with FP modifier or ICD-10 DX.

Code: 64435 — Paracervical injection; Coverage: covered; Payment ranges shown; Units: per procedure; Billing: Bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Codes: 76830/76856/76857 — Pelvic/transvaginal ultrasounds (complete/limited); Coverage: covered; Payments vary by provider type (examples $46.50–$76.50 for 76830; $88.59–$131.63 for 76856; $26.64–$131.63 for 76857); Units: per procedure; Frequency: once per day; Billing: Must bill with FP modifier or ICD-10 DX.

Program-covered services (excerpt)

Per-chart coverage and billing instructions for the listed procedures/tests

Code: 76857 — Pelvic ultrasound (limited/follow-up); Coverage: covered; Payment examples vary by provider/type (chart shows values such as $131.63 and lower FP rows $26.64); Units: per procedure; Frequency: once per day; Billing: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Code: 80048 — Basic metabolic panel (panel components listed in chart); Coverage: covered; Payment: $9.36; Units: per test; Frequency: once per day; Billing: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Code: 80053 — Comprehensive metabolic panel (panel components listed); Coverage: covered; Payment example in chart (e.g., $11.69); Units: per test; Frequency: once per day; Billing: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Code: 80061 — Lipid panel (components listed); Coverage: covered; Payment: $14.00; Units: per test; Frequency: once per day; Billing: Bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Per-code coverage and billing rules (excerpt)

Coverage rows and operational notes for listed CPTs

Code: 80061 — Lipid panel; Reimbursement: $14.00; Unit: per test; Frequency: once per day; Billing note: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Code: 80076 — Hepatic function panel; Reimbursement: $9.03; Unit: per test; Frequency: once per day; Billing note: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Codes: 81000–81003/81001 etc. — Urinalysis CPTs; Reimbursement examples: $4.32 (81000) and values $3.00–$4.37 for automated/non-automated variants; Unit: per test; Frequency: once per day; Billing note: Bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Codes, Descriptions, and Frequency Rules

Procedure codes and descriptionsCPTCovered

11976	Removal, implantable contraceptive capsules
11981	Insertion, drug-delivery implant (bioresorbable/biodegradable/non-biodegradable)
11982	Removal, non-biodegradable drug delivery implant
11983	Removal with reinsertion, non-biodegradable drug delivery implant
55200	Vasotomy, cannulization with or without incision of vas
55250	Vasectomy, including postoperative semen examination(s)
58301	Insertion/removal of intrauterine device (IUD)

Procedures and tests listedmixedCovered

58301	Insertion/removal of intrauterine device (IUD)
58340	Catheterization/sonohysterography or hysterosalpingography
58565	Hysteroscopy with bilateral fallopian tube cannulation (placement of permanent implants)
58600	Ligation/transection of fallopian tube(s)
58615	Occlusion of fallopian tube(s) by device
58670	Laparoscopy with fulguration of oviducts
58671	Laparoscopy with occlusion of oviducts by device
74740	Hysterosalpingography, radiological supervision and interpretation
81025	Urine pregnancy test, visual color comparison
84703	Gonadotropin, chorionic (hCG); qualitative

Covered laboratory and E/M codes in excerptCPT | HCPCS | mixedCovered

84703	Gonadotropin, chorionic (hCG); qualitative
87480	Infectious agent detection by nucleic acid; Candida species, direct probe technique
87510	Infectious agent detection by nucleic acid; Gardnerella vaginalis, direct probe technique
87521	Infectious agent detection by nucleic acid; hepatitis C, amplified probe technique
87660	Infectious agent detection by nucleic acid; Trichomonas vaginalis, direct probe technique
87661	Infectious agent detection by nucleic acid; Trichomonas vaginalis, amplified probe technique
99202	Office/outpatient visit for evaluation and management, new patient, ~15 minutes
99203	Office/outpatient visit for evaluation and management, new patient, ~30 minutes
99204	Office/outpatient visit for evaluation and management, new patient, ~45 minutes
99205	Office/outpatient visit for evaluation and management, new patient, ~60 minutes

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E/M and preventive medicine CPT codesCPTCovered

99205	Office/outpatient new patient E/M, high level; time threshold 60 minutes; reimbursed $209.15; per visit; once per day; provider must bill with FP modifier or ICD-10 DX
99211	Office/outpatient established patient E/M; reimbursed $20.00; per visit; limited to one per year; bill with FP modifier or ICD-10 DX
99212	Established patient E/M, straightforward; time threshold 10 minutes; reimbursed $70.58; per visit; once per day; bill with FP modifier or ICD-10 DX
99213	Established patient E/M, low level; time threshold 20 minutes; reimbursed $116.48; per visit; once per day; bill with FP modifier or ICD-10 DX
99214	Established patient E/M, moderate level; time threshold 30 minutes; reimbursed $141.33; per visit; once per day; bill with FP modifier or ICD-10 DX
99215	Established patient E/M, high level; time threshold 40 minutes; reimbursed $137.24 (as listed); per visit; once per day; bill with FP modifier or ICD-10 DX
99384	Initial comprehensive preventive medicine (adolescent 12-17); reimbursement shown ($126.41); per visit; annual combination limits with related codes
99385	Initial comprehensive preventive medicine (18-39); reimbursed $144.58; per visit; must bill with FP modifier or ICD-10 Z30.011–Z30.9
99386	Initial comprehensive preventive medicine (40-64); reimbursed $167.09; per visit; must bill with FP modifier or ICD-10 Z30.011–Z30.9
99394	Periodic preventive medicine (adolescent 12-17); reimbursed $107.53; per visit; annual combination limits with related codes

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Listed covered procedure and supply codesmixedCovered

99395	Periodic comprehensive preventive medicine reevaluation and management; established patient 18-39 yrs
99396	Periodic comprehensive preventive medicine reevaluation and management; established patient 40-64 yrs
99401	Preventive medicine counseling; approximately 15 minutes
A4264	Permanent implantable contraceptive intratubal occlusion device(s) and delivery system
A4266	Diaphragm for contraceptive use
A4267	Contraceptive supply, condom, male, each
A4268	Contraceptive supply, condom, female, each
J7296	Levonorgestrel-releasing IUS (Kyleena) 19.5 mg
J7297	Levonorgestrel-releasing IUS (Liletta) 52 mg
J7298	Levonorgestrel-releasing IUS (Mirena) 52 mg

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Procedure codes in excerptCPTCovered

11420	Excision, benign lesion; excised diameter 0.5 cm or less
11421	Excision, benign lesion; excised diameter 0.6 to 1.0 cm
11422	Excision, benign lesion; excised diameter 1.1 to 2.0 cm
11423	Excision, benign lesion; excised diameter 2.1 to 3.0 cm
11424	Excision, benign lesion; excised diameter 3.1 to 4.0 cm
11426	Excision, benign lesion; excised diameter over 4.0 cm
17000	Destruction, premalignant lesions; first lesion
17003	Destruction, premalignant lesions; second through 14 lesions, each
17004	Destruction, premalignant lesions; 15 or more lesions
17110	Destruction, benign lesions other than skin tags; up to 14 lesions

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Procedure codes appearing in chart excerptCPTCovered

17004	Destruction of premalignant lesions (15 or more)
17110	Destruction of benign lesions, up to 14 lesions
17111	Destruction of benign lesions, 15 or more lesions
46900	Destruction of lesion(s), anus; simple; chemical
46910	Destruction of lesion(s), anus; simple (other technique)
46916	Destruction of lesion(s), anus; electrodesiccation/cryosurgery
46917	Destruction of lesion(s), anus; laser surgery
46922	Destruction of lesion(s), anus; surgical excision
46924	Destruction of lesion(s), anus; extensive surgical excision
54050	Destruction/excision of lesion(s), penis (simple)

Selected CPT procedures listed in this excerptCPTCovered

46924	Destruction of lesion(s), anus (eg, condyloma)
54050	Destruction of lesion(s), penis, simple; chemical
56405	Incision and drainage of vulva or perineal abscess

Additional CPT procedures in excerptCPTCovered

54055	Destruction of lesion(s), penis; electrodesiccation
54056	Destruction of lesion(s), penis; cryosurgery
54060	Destruction of lesion(s), penis; surgical excision

Further CPT proceduresCPTCovered

54057	Destruction of lesion(s), penis; laser surgery
54065	Destruction of lesion(s), penis; extensive
56420	Incision and drainage of Bartholin's gland abscess

Listed CPT codes and short descriptorsCPTCovered

56405	Incision and drainage of vulva or perineal abscess
56420	Incision and drainage of Bartholin's gland abscess
56440	Marsupialization of Bartholin's gland cyst
56501	Destruction of lesion(s), vulva; simple
56515	Destruction of lesion(s), vulva; extensive
56606	Biopsy of vulva or perineum (separate procedure)
56820	Colposcopy of the vulva
56821	Colposcopy of the vulva; with biopsy(s)

Colposcopy of vulvaCPTCovered

56821

Colposcopy of the vulva; with biopsy(s)

Destruction of vaginal lesion(s) - simpleCPTCovered

57061

Destruction of vaginal lesion(s); simple

Destruction of vaginal lesion(s) - extensive / biopsy mappingCPTCovered

57100

Destruction of vaginal lesion(s); extensive

Biopsy - extensiveCPTCovered

57150

Biopsy of vaginal mucosa; extensive, requiring suture

Colposcopy - entire vaginaCPTCovered

57420

Colposcopy of the entire vagina, with cervix if present

Colposcopy with biopsyCPTCovered

57421

Colposcopy of the entire vagina, with biopsy(s) of vagina/cervix

Colposcopy of cervix/upper vaginaCPTCovered

57452

Colposcopy of the cervix including upper/adjacent vagina

Colposcopy codes (example 57421)CPTCovered

57421

Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix

Colposcopy codes (example 57452)CPTCovered

57452

Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of vagina/cervix

Colposcopy codes (example 57454)CPTCovered

57454

Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) and endocervical curettage

Colposcopy codes (example 57455)CPTCovered

57455

Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix

Colposcopy codes (example 57456)CPTCovered

57456

Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage

Colposcopy codes (example 57460)CPTCovered

57460

Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s)

Colposcopy codes (example 57461)CPTCovered

57461

Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization

CPT codes listed in chartCPTCovered

57461	Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix / conization
57500	Biopsy of cervix, single or multiple, or local excision of lesion
57505	Endocervical curettage
57510	Cautery of cervix; electro or thermal
57511	Cautery of cervix; cryocautery, initial or repeat
57513	Cautery of cervix; laser ablation
57520	Conization of cervix, cold knife or laser
57522	Conization of cervix; loop electrode excision
57800	Dilation of cervical canal, instrumental (separate procedure)

Listed family planning procedure codes and descriptionsCPTCovered

57800	Dilation of cervical canal, instrumental (separate procedure)
58100	Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation
58110	Endometrial sampling (biopsy) performed in conjunction with colposcopy
58562	Hysteroscopy, surgical; with removal of impacted foreign body
64435	Injection(s), anesthetic agent(s) and/or steroid; paracervical (uterine) nerve
76830	Ultrasound, transvaginal
76856	Ultrasound, pelvic (nonobstetric), real time with image documentation; complete
76857	Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up

Pelvic ultrasoundCPTCovered

76857

Ultrasound, pelvic (nonobstetric), real time with image documentation; complete or limited/follow-up

Chemistry panelsCPTCovered

80048	Basic metabolic panel (Calcium, total; CO2; Chloride; Creatinine; Glucose; Potassium; Sodium; BUN)
80053	Comprehensive metabolic panel (panel components listed in chart)

Lipid testingCPTCovered

80061

Lipid panel (Total cholesterol, HDL direct, Triglycerides)

Covered laboratory CPT codes (excerpt)CPT | mixedCovered

80061	Lipid panel (includes 82465, 83718, 84478)
80076	Hepatic function panel (includes 82040, 82247, 82248, 84075, 84155, 84460, 84450)
81000	Urinalysis, non-automated, with microscopy
81001	Urinalysis, automated, with microscopy
81002	Urinalysis, non-automated, without microscopy
81003	Urinalysis, automated, without microscopy

Frequency Limits, Time Thresholds, and Definitions

inv-49: Frequency limits

Example: IUD (58301)Limit: 1 per 3 calendar years (per procedure); post-op days: 0 days

Example: Implant removal (11976)Limit: 1 per 3 calendar years (per procedure); post-op days: 0 days

Example: Vasectomy (55250)Limit: once per lifetime (per procedure)

inv-50: Frequency limits examples

IUD insertion/removal (58301)1 per 3 calendar years (per procedure); example allowed amounts shown ($174.03; $366.78)

Hysteroscopy with implant placement (58565)Once per lifetime (per procedure); 90 days noted in some rows

Sterilization (58600 series)Varies by code: two per lifetime or once per lifetime in some rows; per procedure billing unit

inv-51: visit_frequency

E/M visits (99202–99205)Billed per visit; typical frequency: once per day; must meet time thresholds when time is used for code selection

Established visit (99211)Billed per visit; limited to one per year for listed entries

All E/M codesProviders instructed to bill with FP modifier or ICD-10 Z30 family-planning diagnosis where indicated

inv-52: time-based code selection thresholds

99205When selecting by total time on date of encounter: 60 minutes must be met or exceeded

99212When selecting by total time on date of encounter: 10 minutes must be met or exceeded

99213When selecting by total time on date of encounter: 20 minutes must be met or exceeded

99214When selecting by total time on date of encounter: 30 minutes must be met or exceeded

99215When selecting by total time on date of encounter: 40 minutes must be met or exceeded

inv-53: preventive service frequency rules

Preventive codes (99384–99386; 99394–99396)Annual combination limits apply: per visit billing with specified per-year combination limits across these codes

99395/99396Typically billed 'per visit' and subject to annual combination limits with related preventive codes

Billing requirementPreventive codes must be billed with FP modifier or ICD-10 Z30.011–Z30.9 where indicated

inv-54: Frequency limits

99395 / 99396Billed 'per visit'; examples: 99395 = $110.60; 99396 = $120.25

99401Limit: once per lifetime (preventive counseling)

A4264 / A4266A4264 (permanent intratubal device) once per lifetime; A4266 (diaphragm) two per 365 days

inv-55: Reimbursement examples

99395 reimbursement$110.60 (example shown in chart)

99396 reimbursement$120.25 (example shown in chart)

A4264 reimbursement$1,300.00 (device; example shown in chart)

inv-56: Per-procedure limits / frequency

Excision/destruction codesMost entries specify 'per procedure' unit and often 'once per day' frequency; follow-up/global intervals (e.g., 10 days) appear in many rows

Examples (17110/17111)Lesion destruction codes show per-procedure billing with daily limits and associated post-op day rules

Administrative reviewSome high-fee or extensive-procedure rows note AUR/PSR process may apply

inv-57: lesion count limits

17110 (benign lesions)Limited to up to 14 lesions (separate entry); billed per procedure with indicated fees

17111 (15+ lesions)Applies to 15 or more lesions; separate per-procedure entries with their own fees and limits

Lesion-count billing guidanceChart differentiates fee/limit by lesion count (up to 14 vs 15+)

inv-58: frequency limit

Typical frequency unitMany entries list billing unit as 'per procedure' and frequency 'once per day'

Follow-up interval'10 days' commonly appears as a related interval or global/follow-up period in excision/destruction rows

Per-procedure examplesEntries for anal/vulvar procedures show per-procedure billing and daily/10-day notes

inv-59: frequency limit / interval

General patternMost procedure rows show 'per procedure' billing unit and 'once per day' frequency; some rows also indicate 0 days or 10 days where applicable

Examples of intervalsChart entries include specific intervals such as 0 days, 10 days, and 90 days depending on code/provider

Billing noteProvider must bill with FP modifier or ICD-10 Z30.* as specified in many rows

inv-60: frequency limits

Per-procedure + daily defaultMost CPT lines list unit 'per procedure' with default frequency 'once per day' unless otherwise noted

Exceptions notedSome entries display 0 days or 10 days in the day/interval fields for follow-up or global periods

PSR/AUR statusMany rows explicitly state PSR/AUR applies or 'No' as applicable

inv-62: global_payment_examples

Example allowed amountsChart shows example allowed amounts across procedures (e.g., $105.72; $120.58; $607.00)

Fee varietyMultiple allowed amounts shown per code depending on provider type/setting

Billing requirementFees apply when billed with FP modifier or ICD-10 Z30.* as specified

inv-63: frequency

Common frequency statementsPer procedure; once per day is the common frequency assignment across many codes

Specific intervalsSome codes show one per 90 days or N/A where applicable

Day fieldsEntries show 0 days, 10 days, or 90 days depending on the CPT and provider row

inv-64: Per-procedure frequency / interval

Per-procedure billing unitMany procedures are billed 'per procedure' with explicit 'once per day' frequency; some rows list 0, 10, or 90 days intervals

Example: 57522 (conization)Listed as per procedure; once per day; 90 days interval shown for repeat procedures in some rows

Provider billing instructionRows instruct billing with FP modifier or ICD-10 Z30.* as appropriate

inv-65: frequency

Default frequencyPer procedure; once per day is typical; some entries explicitly list 0 days where noted

Provider-specific variationValues (fees/intervals) vary by provider type and place of service across rows

Administrative review noteCertain rows include AUR/PSR references for review processes

inv-66: frequency

Laboratory/test frequencyMost lab and ultrasound entries list frequency 'once per day' (per test/per procedure)

Unit: per test/procedureLabs and imaging billed per test or per procedure with once-per-day default

Billing identifierMust bill with FP modifier or ICD-10 Z30.011–Z30.9 as specified for family-planning services

inv-67: frequency limit

Urinalysis and panels (81000–81003; 80048; 80053; 80061)Each test listed as 'per test' with frequency 'once per day' and must be billed with FP modifier or ICD-10 Z30.*

Example reimbursements80061 (lipid panel) $14.00; 80076 $9.03; 81003 $3.10 (examples from chart)

Billing rulePer-test limits: once per day; chart requires FP modifier or Z30 diagnosis where indicated

Billing, Authorization, and Administrative Review Requirements

Prior Authorization

Prior authorization and review processes

Prior authorization is not required for program services (Prior Auth = No). However, many rows note that Automated Utilization Review (AUR) and Post‑Service Review (PSR) processes may apply — e.g., entries marked “No, but AUR and PSR process” or “and PSR process.”

Prior Auth = No for listed procedures.
Some provider-type rows explicitly state: “No, but AUR and PSR process” or similar, indicating post‑payment administrative review may occur.

Documentation Required

Billing requirements tied to authorization/review

Bill family planning services using the program billing identifier: either the FP info modifier or an ICD‑10 family‑planning diagnosis code (Z30.011–Z30.9) as directed in the chart. Several code rows also indicate that AUR/PSR processes may apply.

When chart comments specify, bill with FP modifier or ICD‑10 DX Z30.011–Z30.9.
AUR/PSR may apply to some entries even when Prior Auth = No.

Billing Rule

Billing modifier and administrative review requirements

Providers must include the FP modifier or an ICD‑10 family planning diagnosis (Z30.011–Z30.9) on claim lines for many listed procedures; several entries also indicate that AUR/PSR administrative review applies to those claims.

Charted requirement: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”
Some rows show “No, but AUR and PSR process applies” or reference PSR/AUR alongside the billing requirement.

Billing Rule

Billing modifier requirement for family planning services

For family planning services and related tests, bill with the FP info modifier or use an ICD‑10 family‑planning diagnosis (Z30.011–Z30.9) on the claim — the chart repeatedly states this requirement for applicable provider types.

Example statement in multiple rows: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”

Billing Rule

E/M visit billing instructions

When submitting E/M visit codes (office/outpatient), follow per‑visit frequency limits and bill with the FP modifier or an ICD‑10 family‑planning diagnosis (Z30.011–Z30.9) as specified in the chart.

E/M codes are billed per visit and typically limited to once per day; 99211 is limited to one per year in some rows.
Chart instructions: “bill with the FP modifier or with the ICD‑10 DX.”

Billing Rule

Billing requirement: FP modifier or ICD-10 Z30 diagnosis

Many preventive and E/M CPT codes must be billed with the FP modifier or with an ICD‑10 family‑planning diagnosis code (Z30.011–Z30.9) and are subject to the chart’s frequency limits (e.g., per visit, once per day, annual limits).

Examples: 99205, 99202–99205, 99395/99396 require FP modifier or Z30.* diagnosis where noted.
Frequency rules (per visit, once per day, one per year) apply as listed in the chart.

Prior Authorization

AUR/PSR notification

Some anesthesia and other entries are identified for administrative review: AUR and PSR processes apply to certain anesthesia/provider rows — claims may be subject to automated or post‑service review even when prior authorization is not required.

Examples: anesthesia codes (00921, 00940) note “No, but AUR and PSR process applies.”
Chart rows frequently include PSR/AUR flags indicating potential post‑payment review.

Billing Rule

FP modifier / ICD-10 Z30.x billing requirement

Certain devices and supply codes (and other listed items) require billing with the FP modifier or with an ICD‑10 family‑planning diagnosis (Z30.011–Z30.9); follow the charted billing identifier exactly when submitting claims.

Examples: A4264 entries and device rows state: “bill with the FP modifier or with the ICD‑10 DX.”
Panel and supply codes list FP or Z30.* as the required billing identifier.

Documentation Required

Administrative review processes

The chart indicates administrative review (AUR) and post‑service review (PSR) apply to many codes; some rows explicitly state Prior Auth = No but note that AUR/PSR still applies to claims.

Multiple code rows include the note: “No, but AUR and PSR process applies.”
PSR/AUR flags are shown per code/provider‑type across the chart.

Documentation Required

Administrative utilization review and payment review (AUR/PSR)

Some provider/code combinations are subject to Administrative Utilization Review (AUR) and Provider‑Specific/Post‑Service Review (PSR) — the chart marks these combinations (e.g., 17110) as subject to AUR/PSR even when prior authorization is not required.

Example: 17110 rows state: “No, but AUR and PSR process applies.”
Rows for other procedures similarly flag AUR/PSR in the comments column.

Billing Rule

Billing requirement — FP modifier or ICD-10 Z30.*

Several entries explicitly require billing with either the FP modifier or an ICD‑10 family‑planning diagnosis (Z30.011–Z30.9); follow the chart’s instruction for those specific codes when submitting claims.

Example chart language: “This provider type must bill with the ICD‑10 DX Z30.011 through Z30.9” or “This provider type must bill with the FP modifier.”
This requirement appears across multiple CPT/HCPCS rows.

Billing Rule

Billing modifier/diagnosis requirement

For many provider types the chart repeats the requirement to bill with the FP modifier or with an ICD‑10 family‑planning diagnosis (Z30.011–Z30.9); ensure claims for listed services include one of these identifiers.

Common comment in rows: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”

Denial Risk

Prior review / post-service review flags

Some code rows include post‑service review flags (PSR/AUR). Even when prior authorization is not required, claims may be flagged for PSR/AUR as indicated in the chart (examples: “No, but AUR and PSR process”).

Monitor for PSR/AUR indicators in the chart comments per code/provider type.
PSR/AUR may result in retrospective review of claims.

Documentation Required

PSR/AUR process notes

The chart reiterates: for many listed procedures the provider must bill with the FP modifier or with ICD‑10 family‑planning diagnosis codes Z30.011–Z30.9 — follow the exact billing identifier shown on each row.

Rows explicitly state: “bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”
This instruction appears across procedure, supply and test entries.

Billing Rule

FP modifier / ICD-10 billing requirement

Provider rows across the chart require using the FP modifier or ICD‑10 family planning diagnosis (Z30.011–Z30.9) for many services; claims missing these identifiers risk incorrect processing or review.

Chart language: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”
Apply the billing identifier at the line level for each applicable CPT/HCPCS code.

Billing Rule

Diagnosis billing requirement / FP modifier instruction

Some procedure rows require an ICD‑10 family‑planning diagnosis (Z30.011–Z30.9) specifically as the billing diagnosis; ensure the diagnosis linkage is present when submitting claims for those procedures.

Example: 57061 and 58100 rows state: “This provider type must bill with the ICD‑10 DX Z30.011 through Z30.9.”
Where the chart directs ICD‑10 DX, include the Z30.* diagnosis on the claim.

Documentation Required

AUR and PSR process applies

Multiple chart rows state “No, but AUR and PSR process applies,” indicating that although prior authorization is not required, claims may be subject to automated utilization review or post‑service review procedures.

This flag appears for a variety of procedure and device codes (e.g., colposcopy and destruction procedures).
Expect potential retrospective review when these flags are present.

Billing Rule

Billing requirement — FP modifier or Z30 diagnosis

Where the chart requires the family‑planning billing identifier, providers must bill with the FP modifier or include ICD‑10 diagnosis Z30.011–Z30.9 on the claim — this requirement is repeated for many CPT/HCPCS entries.

Typical row note: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”
Apply to procedure, test, device, and visit codes as specified.

Documentation Required

Administrative review processes (AUR / PSR)

Many rows reference AUR and PSR administrative review processes; when those flags appear on code rows, claims may be reviewed post‑service even if prior authorization was not required.

Examples: colposcopy codes (57452) and various biopsy/excision codes include AUR/PSR language.
Follow documentation and billing requirements to reduce risk of administrative review findings.

Documentation Required

Diagnosis linkage requirement

Certain procedure entries explicitly require linkage to an ICD‑10 family‑planning diagnosis (Z30.011–Z30.9) on the claim; include the specified diagnosis when billing those services.

Statement in chart: “This provider type must bill with the ICD‑10 DX Z30.011 through Z30.9.”
Used for procedures such as biopsies and endometrial sampling in specified rows.

Billing Rule

FP modifier or diagnosis required

Across many provider‑type rows the chart repeats: include either the FP modifier or an ICD‑10 family‑planning diagnosis (Z30.011–Z30.9) on claims for listed services; failure to include one of these may result in processing errors or review.

Common comment: “This provider type must bill with the FP modifier or with the ICD‑10 DX.”
Applies to visits, procedures, tests and device/supply codes shown in the chart.

Billing Rule

Frequency limits

The chart shows per‑procedure frequency and interval limits (e.g., per procedure, once per day; some procedures have 90‑day intervals); ensure claims respect these frequency constraints when billing.

Examples: many procedures are billed “per procedure; once per day.”
Some colposcopy and conization entries list “one per 90 days” or 90‑day intervals.

Documentation Required

ICD-10 billing requirement for family planning services

For many family‑planning services the chart requires billing with ICD‑10 diagnosis codes Z30.011–Z30.9 as the family‑planning diagnosis; include Z30.* when the row specifies it.

Rows state: “This provider type must bill with the ICD‑10 DX Z30.011 through Z30.9.”
Apply across procedure, test and panel entries when specified.

Billing Rule

FP modifier or ICD-10 requirement

The FP modifier or ICD‑10 Z30.011–Z30.9 requirement is repeated throughout the chart for many provider types and CPT/HCPCS codes; follow the specified billing identifier on each row.

Examples: pelvic ultrasound (76857), lab panels (80061) and many procedure codes include this requirement.
The chart typically repeats: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”

Billing Rule

Billing requirement for Family Planning provider type

Family Planning provider‑type rows for tests and procedures consistently require either the FP modifier or ICD‑10 family‑planning diagnosis (Z30.011–Z30.9); ensure the claim line includes one of these identifiers for payment.

Panel and test rows (80048, 80061, etc.) state: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”
Apply to lab panels, ultrasounds and other listed services.

Billing Rule

Billing modifier/diagnosis requirement

The chart repeats the billing modifier/diagnosis requirement: include the FP modifier or ICD‑10 Z30.011–Z30.9 on claims for listed provider types and services to align with program billing rules.

Multiple test and panel rows show the instruction: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”

Billing Rule

Billing modifier/diagnosis requirement (repeated)

The FP modifier or ICD‑10 Z30.* billing requirement is repeated across many CPT rows; providers should ensure consistent application of the FP modifier or Z30 diagnosis across all applicable claims.

Entries for panels and urinalysis (81000–81003) repeat the requirement to bill with the FP modifier or ICD‑10 Z30.*.
Consistency across claim lines reduces risk of denial or administrative review.

Program Definitions and Billing Identifiers

inv-95: FP modifier / ICD-10 Z30.011–Z30.9 requirement

FP modifier (program billing modifier)Info modifier required for many provider types when billing Family Planning Services; shown repeatedly in chart entries

ICD-10 family planning diagnosis rangeICD-10 Dx Z30.011 through Z30.9 may be used as alternative billing indicator to the FP modifier

Usage noteRows state: 'This provider type must bill with the FP modifier or with the ICD-10 DX' where applicable

inv-96: AUR and PSR

AUR (Automated Utilization Review)Administrative review process referenced for select codes; chart notes 'AUR process' or 'No, but AUR and PSR process' for some rows

PSR (Post-Service/Provider Specific Review)Post-service review/process (PSR) may apply to some high-cost or procedural entries as noted in chart rows

Provider actionsChart entries indicate when AUR/PSR applies; prior authorization often 'No' but AUR/PSR may still apply

inv-97: FP modifier

FP modifier definition/useBilling modifier indicating Family Planning Services program; required on many provider-type rows in chart

Alternative billingICD-10 Z30.011–Z30.9 may be billed in lieu of FP modifier as noted in many rows

Chart languageEntries state: 'This provider type must bill with the FP modifier or with the ICD-10 DX Z30.011 through Z30.9'

inv-98: AUR and PSR

AUR and PSR processes (administrative review)Described as administrative/utilization review processes applied to certain claims; chart rows reference these as potential review steps

When appliedUsed on select procedure/provider combinations; chart notes 'No, but AUR and PSR process' or 'and PSR process'

Implication for billingClaims may undergo automated or post-payment review even when prior auth is 'No'

inv-99: FP modifier

FP modifier requirement (repeated)Chart repeatedly requires the FP modifier for providers billing family planning services (or alternative Z30 diagnosis)

Explicit chart wordingMany rows state: 'This provider type must bill with the FP modifier or with the ICD-10 DX'

Applies across servicesRequirement appears on preventive, E/M, lab, imaging, and procedure rows as indicated

inv-100: ICD-10 DX Z30.011–Z30.9

ICD-10 Z30.011–Z30.9 rangeRange of family planning diagnosis codes referenced as acceptable billing diagnoses in chart rows

Alternative to FP modifierRows indicate billing with Z30.011–Z30.9 instead of FP modifier is acceptable where noted

Chart examplesMultiple entries state billing 'with the ICD-10 DX Z30.011 through Z30.9'

inv-102: Time-based E/M selection

Time-based E/M selection summaryTotal time on date of encounter may be used for E/M code selection; thresholds shown (e.g., 99205=60min; 99212=10min; 99213=20min; 99214=30min; 99215=40min)

Billing contextWhen time is used for selection, encounter total time must meet or exceed listed minutes per code

Applies to visit rulesThese thresholds are referenced in E/M visit rows for new and established patients

Policy Summary

PayerPennsylvania Insurance Department

PolicyFamily Planning Services Program — Covered Services Chart

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDec 30, 2025

Last ReviewDec 30, 2025

Next Review DateN/A

Key ActionWhen billing family planning services, include the FP modifier or ICD-10 diagnosis Z30.011–Z30.9 as indicated on each procedure row.

SourceLink

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Family Planning Services Program — Covered Services Chart

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Coverage Criteria and Per-Procedure Rules

Per-procedure coverage criteria rows (sampled)

Per-code coverage rows (examples below) provide the program stance and billing rules.

Coverage rows and constraints

Code: 81025 — Urine pregnancy test (visual); Payment: $10.76; Units: per test; Frequency: once per day; Prior auth: No; Billing: Must bill with FP modifier or ICD-10 DX.

Code: 84703 — hCG qualitative test; Payment: $10.26; Units: per test; Frequency: once per day; Prior auth: No; Billing: Must bill with FP modifier or ICD-10 DX.

Coverage criteria and billing rules (excerpt)

Codes listed are included in the Family Planning Services Program with specified allowed amounts, billing units, and required billing modifiers or diagnosis codes.

Visit rule: When using total time on date of encounter for E/M selection, required thresholds must be met or exceeded (examples: 99202=15 min; 99203≈30 min; 99204≈45 min; 99205=60 min).

Coverage and billing criteria (excerpt)

Coverage applies to listed CPT E/M and preventive CPT codes when billed according to program rules:

Requirement: Provider must bill with FP modifier or with the ICD-10 diagnosis Z30.011–Z30.9 where indicated in the chart.

Payment: Reimbursement amounts are listed per code in the chart and apply when billing rules (modifier/diagnosis, unit, frequency) are followed.

Coverage criteria for charted family planning services

Coverage and billing requirements for listed family planning services and supplies.

Frequency examples: 99401 once per lifetime; A4264 once per lifetime; A4266 two per 365 days; contraceptive supplies (A4267/A4268) 144 per 30 days where listed.

Reimbursement examples from chart: 99395 $110.60; 99396 $120.25; A4264 $1,300.00; J7296 (Kyleena) listed at program device pricing in chart.

Utilization review: AUR and PSR processes apply to select anesthesia or device rows; prior authorization status varies by code/provider row.

Per-code coverage entries (examples)

Coverage and billing requirements shown per procedure code include payment amounts, whether AUR/PSR applies, frequency/limits, and billing modifiers/diagnosis requirements.

Per-code coverage criteria (excerpted rows)

Per-code coverage entries include allowed service descriptions, payment amounts, provider-type specifics, required billing diagnosis or modifier, frequency, and administrative review notes.

Procedure-level coverage rules (excerpt)

Coverage and billing guidance for listed CPT procedures in the Family Planning Services Program:

Billing diagnosis/modifier rule: Provider must bill listed procedure codes with the FP modifier or with ICD-10 diagnosis codes Z30.011–Z30.9 where indicated in the chart.

Payment amounts: Each procedure row includes a listed payment amount (examples in extract: 46924 $230.08; 54050 $129.69; 54055/54057/54065/56405 fees as shown).

Billing unit/frequency: Entries specify billing unit as 'per procedure' and commonly list 'once per day'; some entries indicate a 10-day follow-up or 90-day intervals as applicable.

Utilization review: Some codes note 'No, but AUR and PSR process' or reference PSR/AUR indicating possible administrative review for certain provider/code combinations.

Coverage nodes for this chart segment

Coverage and billing conditions shown for each CPT code include:

General rule: CPT code is covered when billed with the FP modifier or with ICD-10 DX Z30.011–Z30.9 where specified in the chart.

Unit/frequency: Unit is typically 'per procedure'; frequency is often 'once per day' unless otherwise noted; some codes show 0 days or a 10-day related interval.

PSR/AUR: Some procedures indicate PSR and/or AUR processes apply; many entries explicitly state 'No' for PSR while others note administrative review may occur.

Procedure-specific coverage nodes

Per-procedure coverage details and billing instructions found in the chart excerpt:

Select procedure coverage rows (excerpt)

Procedure-specific coverage rows include required billing modifiers/diagnoses, payment amounts, frequency limits, and administrative process notes.

Example CPT entry: 57461

Coverage entries by CPT code include: payment amount, whether PSR/AUR applies, billing modifier/diagnosis requirement, frequency and day/interval limits.

Example CPT entry: 57522

Conization and excision procedures

Example CPT entry: 57800

Dilation procedures

Per-code coverage entries (excerpt)

Per-procedure coverage entries include payment amount, whether AUR/PSR processes apply, frequency limits, and billing modifier or diagnosis requirements.

Code: 64435 — Paracervical injection; Coverage: covered; Payment ranges shown; Units: per procedure; Billing: Bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Program-covered services (excerpt)

Per-chart coverage and billing instructions for the listed procedures/tests

Code: 80061 — Lipid panel (components listed); Coverage: covered; Payment: $14.00; Units: per test; Frequency: once per day; Billing: Bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Per-code coverage and billing rules (excerpt)

Coverage rows and operational notes for listed CPTs

Code: 80061 — Lipid panel; Reimbursement: $14.00; Unit: per test; Frequency: once per day; Billing note: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Code: 80076 — Hepatic function panel; Reimbursement: $9.03; Unit: per test; Frequency: once per day; Billing note: Must bill with FP modifier or ICD-10 DX Z30.011–Z30.9.

Codes, Descriptions, and Frequency Rules

Procedure codes and descriptionsCPTCovered

11976	Removal, implantable contraceptive capsules
11981	Insertion, drug-delivery implant (bioresorbable/biodegradable/non-biodegradable)
11982	Removal, non-biodegradable drug delivery implant
11983	Removal with reinsertion, non-biodegradable drug delivery implant
55200	Vasotomy, cannulization with or without incision of vas
55250	Vasectomy, including postoperative semen examination(s)
58301	Insertion/removal of intrauterine device (IUD)

Procedures and tests listedmixedCovered

58301	Insertion/removal of intrauterine device (IUD)
58340	Catheterization/sonohysterography or hysterosalpingography
58565	Hysteroscopy with bilateral fallopian tube cannulation (placement of permanent implants)
58600	Ligation/transection of fallopian tube(s)
58615	Occlusion of fallopian tube(s) by device
58670	Laparoscopy with fulguration of oviducts
58671	Laparoscopy with occlusion of oviducts by device
74740	Hysterosalpingography, radiological supervision and interpretation
81025	Urine pregnancy test, visual color comparison
84703	Gonadotropin, chorionic (hCG); qualitative

Covered laboratory and E/M codes in excerptCPT | HCPCS | mixedCovered

84703	Gonadotropin, chorionic (hCG); qualitative
87480	Infectious agent detection by nucleic acid; Candida species, direct probe technique
87510	Infectious agent detection by nucleic acid; Gardnerella vaginalis, direct probe technique
87521	Infectious agent detection by nucleic acid; hepatitis C, amplified probe technique
87660	Infectious agent detection by nucleic acid; Trichomonas vaginalis, direct probe technique
87661	Infectious agent detection by nucleic acid; Trichomonas vaginalis, amplified probe technique
99202	Office/outpatient visit for evaluation and management, new patient, ~15 minutes
99203	Office/outpatient visit for evaluation and management, new patient, ~30 minutes
99204	Office/outpatient visit for evaluation and management, new patient, ~45 minutes
99205	Office/outpatient visit for evaluation and management, new patient, ~60 minutes

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E/M and preventive medicine CPT codesCPTCovered

99205	Office/outpatient new patient E/M, high level; time threshold 60 minutes; reimbursed $209.15; per visit; once per day; provider must bill with FP modifier or ICD-10 DX
99211	Office/outpatient established patient E/M; reimbursed $20.00; per visit; limited to one per year; bill with FP modifier or ICD-10 DX
99212	Established patient E/M, straightforward; time threshold 10 minutes; reimbursed $70.58; per visit; once per day; bill with FP modifier or ICD-10 DX
99213	Established patient E/M, low level; time threshold 20 minutes; reimbursed $116.48; per visit; once per day; bill with FP modifier or ICD-10 DX
99214	Established patient E/M, moderate level; time threshold 30 minutes; reimbursed $141.33; per visit; once per day; bill with FP modifier or ICD-10 DX
99215	Established patient E/M, high level; time threshold 40 minutes; reimbursed $137.24 (as listed); per visit; once per day; bill with FP modifier or ICD-10 DX
99384	Initial comprehensive preventive medicine (adolescent 12-17); reimbursement shown ($126.41); per visit; annual combination limits with related codes
99385	Initial comprehensive preventive medicine (18-39); reimbursed $144.58; per visit; must bill with FP modifier or ICD-10 Z30.011–Z30.9
99386	Initial comprehensive preventive medicine (40-64); reimbursed $167.09; per visit; must bill with FP modifier or ICD-10 Z30.011–Z30.9
99394	Periodic preventive medicine (adolescent 12-17); reimbursed $107.53; per visit; annual combination limits with related codes

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Listed covered procedure and supply codesmixedCovered

99395	Periodic comprehensive preventive medicine reevaluation and management; established patient 18-39 yrs
99396	Periodic comprehensive preventive medicine reevaluation and management; established patient 40-64 yrs
99401	Preventive medicine counseling; approximately 15 minutes
A4264	Permanent implantable contraceptive intratubal occlusion device(s) and delivery system
A4266	Diaphragm for contraceptive use
A4267	Contraceptive supply, condom, male, each
A4268	Contraceptive supply, condom, female, each
J7296	Levonorgestrel-releasing IUS (Kyleena) 19.5 mg
J7297	Levonorgestrel-releasing IUS (Liletta) 52 mg
J7298	Levonorgestrel-releasing IUS (Mirena) 52 mg

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Procedure codes in excerptCPTCovered

11420	Excision, benign lesion; excised diameter 0.5 cm or less
11421	Excision, benign lesion; excised diameter 0.6 to 1.0 cm
11422	Excision, benign lesion; excised diameter 1.1 to 2.0 cm
11423	Excision, benign lesion; excised diameter 2.1 to 3.0 cm
11424	Excision, benign lesion; excised diameter 3.1 to 4.0 cm
11426	Excision, benign lesion; excised diameter over 4.0 cm
17000	Destruction, premalignant lesions; first lesion
17003	Destruction, premalignant lesions; second through 14 lesions, each
17004	Destruction, premalignant lesions; 15 or more lesions
17110	Destruction, benign lesions other than skin tags; up to 14 lesions

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Procedure codes appearing in chart excerptCPTCovered

17004	Destruction of premalignant lesions (15 or more)
17110	Destruction of benign lesions, up to 14 lesions
17111	Destruction of benign lesions, 15 or more lesions
46900	Destruction of lesion(s), anus; simple; chemical
46910	Destruction of lesion(s), anus; simple (other technique)
46916	Destruction of lesion(s), anus; electrodesiccation/cryosurgery
46917	Destruction of lesion(s), anus; laser surgery
46922	Destruction of lesion(s), anus; surgical excision
46924	Destruction of lesion(s), anus; extensive surgical excision
54050	Destruction/excision of lesion(s), penis (simple)

Selected CPT procedures listed in this excerptCPTCovered

46924	Destruction of lesion(s), anus (eg, condyloma)
54050	Destruction of lesion(s), penis, simple; chemical
56405	Incision and drainage of vulva or perineal abscess

Additional CPT procedures in excerptCPTCovered

54055	Destruction of lesion(s), penis; electrodesiccation
54056	Destruction of lesion(s), penis; cryosurgery
54060	Destruction of lesion(s), penis; surgical excision

Further CPT proceduresCPTCovered

54057	Destruction of lesion(s), penis; laser surgery
54065	Destruction of lesion(s), penis; extensive
56420	Incision and drainage of Bartholin's gland abscess

Listed CPT codes and short descriptorsCPTCovered

56405	Incision and drainage of vulva or perineal abscess
56420	Incision and drainage of Bartholin's gland abscess
56440	Marsupialization of Bartholin's gland cyst
56501	Destruction of lesion(s), vulva; simple
56515	Destruction of lesion(s), vulva; extensive
56606	Biopsy of vulva or perineum (separate procedure)
56820	Colposcopy of the vulva
56821	Colposcopy of the vulva; with biopsy(s)

Colposcopy of vulvaCPTCovered

56821

Colposcopy of the vulva; with biopsy(s)

Destruction of vaginal lesion(s) - simpleCPTCovered

57061

Destruction of vaginal lesion(s); simple

Destruction of vaginal lesion(s) - extensive / biopsy mappingCPTCovered

57100

Destruction of vaginal lesion(s); extensive

Biopsy - extensiveCPTCovered

57150

Biopsy of vaginal mucosa; extensive, requiring suture

Colposcopy - entire vaginaCPTCovered

57420

Colposcopy of the entire vagina, with cervix if present

Colposcopy with biopsyCPTCovered

57421

Colposcopy of the entire vagina, with biopsy(s) of vagina/cervix

Colposcopy of cervix/upper vaginaCPTCovered

57452

Colposcopy of the cervix including upper/adjacent vagina

Colposcopy codes (example 57421)CPTCovered

57421

Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix

Colposcopy codes (example 57452)CPTCovered

57452

Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of vagina/cervix

Colposcopy codes (example 57454)CPTCovered

57454

Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) and endocervical curettage

Colposcopy codes (example 57455)CPTCovered

57455

Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix

Colposcopy codes (example 57456)CPTCovered

57456

Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage

Colposcopy codes (example 57460)CPTCovered

57460

Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s)

Colposcopy codes (example 57461)CPTCovered

57461

Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization

CPT codes listed in chartCPTCovered

57461	Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix / conization
57500	Biopsy of cervix, single or multiple, or local excision of lesion
57505	Endocervical curettage
57510	Cautery of cervix; electro or thermal
57511	Cautery of cervix; cryocautery, initial or repeat
57513	Cautery of cervix; laser ablation
57520	Conization of cervix, cold knife or laser
57522	Conization of cervix; loop electrode excision
57800	Dilation of cervical canal, instrumental (separate procedure)

Listed family planning procedure codes and descriptionsCPTCovered

57800	Dilation of cervical canal, instrumental (separate procedure)
58100	Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation
58110	Endometrial sampling (biopsy) performed in conjunction with colposcopy
58562	Hysteroscopy, surgical; with removal of impacted foreign body
64435	Injection(s), anesthetic agent(s) and/or steroid; paracervical (uterine) nerve
76830	Ultrasound, transvaginal
76856	Ultrasound, pelvic (nonobstetric), real time with image documentation; complete
76857	Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up

Pelvic ultrasoundCPTCovered

76857

Ultrasound, pelvic (nonobstetric), real time with image documentation; complete or limited/follow-up

Chemistry panelsCPTCovered

80048	Basic metabolic panel (Calcium, total; CO2; Chloride; Creatinine; Glucose; Potassium; Sodium; BUN)
80053	Comprehensive metabolic panel (panel components listed in chart)

Lipid testingCPTCovered

80061

Lipid panel (Total cholesterol, HDL direct, Triglycerides)

Covered laboratory CPT codes (excerpt)CPT | mixedCovered

80061	Lipid panel (includes 82465, 83718, 84478)
80076	Hepatic function panel (includes 82040, 82247, 82248, 84075, 84155, 84460, 84450)
81000	Urinalysis, non-automated, with microscopy
81001	Urinalysis, automated, with microscopy
81002	Urinalysis, non-automated, without microscopy
81003	Urinalysis, automated, without microscopy

Frequency Limits, Time Thresholds, and Definitions

inv-49: Frequency limits

Example: IUD (58301)Limit: 1 per 3 calendar years (per procedure); post-op days: 0 days

Example: Implant removal (11976)Limit: 1 per 3 calendar years (per procedure); post-op days: 0 days

Example: Vasectomy (55250)Limit: once per lifetime (per procedure)

inv-50: Frequency limits examples

IUD insertion/removal (58301)1 per 3 calendar years (per procedure); example allowed amounts shown ($174.03; $366.78)

Hysteroscopy with implant placement (58565)Once per lifetime (per procedure); 90 days noted in some rows

Sterilization (58600 series)Varies by code: two per lifetime or once per lifetime in some rows; per procedure billing unit

inv-51: visit_frequency

E/M visits (99202–99205)Billed per visit; typical frequency: once per day; must meet time thresholds when time is used for code selection

Established visit (99211)Billed per visit; limited to one per year for listed entries

All E/M codesProviders instructed to bill with FP modifier or ICD-10 Z30 family-planning diagnosis where indicated

inv-52: time-based code selection thresholds

99205When selecting by total time on date of encounter: 60 minutes must be met or exceeded

99212When selecting by total time on date of encounter: 10 minutes must be met or exceeded

99213When selecting by total time on date of encounter: 20 minutes must be met or exceeded

99214When selecting by total time on date of encounter: 30 minutes must be met or exceeded

99215When selecting by total time on date of encounter: 40 minutes must be met or exceeded

inv-53: preventive service frequency rules

Preventive codes (99384–99386; 99394–99396)Annual combination limits apply: per visit billing with specified per-year combination limits across these codes

99395/99396Typically billed 'per visit' and subject to annual combination limits with related preventive codes

Billing requirementPreventive codes must be billed with FP modifier or ICD-10 Z30.011–Z30.9 where indicated

inv-54: Frequency limits

99395 / 99396Billed 'per visit'; examples: 99395 = $110.60; 99396 = $120.25

99401Limit: once per lifetime (preventive counseling)

A4264 / A4266A4264 (permanent intratubal device) once per lifetime; A4266 (diaphragm) two per 365 days

inv-55: Reimbursement examples

99395 reimbursement$110.60 (example shown in chart)

99396 reimbursement$120.25 (example shown in chart)

A4264 reimbursement$1,300.00 (device; example shown in chart)

inv-56: Per-procedure limits / frequency

Excision/destruction codesMost entries specify 'per procedure' unit and often 'once per day' frequency; follow-up/global intervals (e.g., 10 days) appear in many rows

Examples (17110/17111)Lesion destruction codes show per-procedure billing with daily limits and associated post-op day rules

Administrative reviewSome high-fee or extensive-procedure rows note AUR/PSR process may apply

inv-57: lesion count limits

17110 (benign lesions)Limited to up to 14 lesions (separate entry); billed per procedure with indicated fees

17111 (15+ lesions)Applies to 15 or more lesions; separate per-procedure entries with their own fees and limits

Lesion-count billing guidanceChart differentiates fee/limit by lesion count (up to 14 vs 15+)

inv-58: frequency limit

Typical frequency unitMany entries list billing unit as 'per procedure' and frequency 'once per day'

Follow-up interval'10 days' commonly appears as a related interval or global/follow-up period in excision/destruction rows

Per-procedure examplesEntries for anal/vulvar procedures show per-procedure billing and daily/10-day notes

inv-59: frequency limit / interval

General patternMost procedure rows show 'per procedure' billing unit and 'once per day' frequency; some rows also indicate 0 days or 10 days where applicable

Examples of intervalsChart entries include specific intervals such as 0 days, 10 days, and 90 days depending on code/provider

Billing noteProvider must bill with FP modifier or ICD-10 Z30.* as specified in many rows

inv-60: frequency limits

Per-procedure + daily defaultMost CPT lines list unit 'per procedure' with default frequency 'once per day' unless otherwise noted

Exceptions notedSome entries display 0 days or 10 days in the day/interval fields for follow-up or global periods

PSR/AUR statusMany rows explicitly state PSR/AUR applies or 'No' as applicable

inv-62: global_payment_examples

Example allowed amountsChart shows example allowed amounts across procedures (e.g., $105.72; $120.58; $607.00)

Fee varietyMultiple allowed amounts shown per code depending on provider type/setting

Billing requirementFees apply when billed with FP modifier or ICD-10 Z30.* as specified

inv-63: frequency

Common frequency statementsPer procedure; once per day is the common frequency assignment across many codes

Specific intervalsSome codes show one per 90 days or N/A where applicable

Day fieldsEntries show 0 days, 10 days, or 90 days depending on the CPT and provider row

inv-64: Per-procedure frequency / interval

Per-procedure billing unitMany procedures are billed 'per procedure' with explicit 'once per day' frequency; some rows list 0, 10, or 90 days intervals

Example: 57522 (conization)Listed as per procedure; once per day; 90 days interval shown for repeat procedures in some rows

Provider billing instructionRows instruct billing with FP modifier or ICD-10 Z30.* as appropriate

inv-65: frequency

Default frequencyPer procedure; once per day is typical; some entries explicitly list 0 days where noted

Provider-specific variationValues (fees/intervals) vary by provider type and place of service across rows

Administrative review noteCertain rows include AUR/PSR references for review processes

inv-66: frequency

Laboratory/test frequencyMost lab and ultrasound entries list frequency 'once per day' (per test/per procedure)

Unit: per test/procedureLabs and imaging billed per test or per procedure with once-per-day default

Billing identifierMust bill with FP modifier or ICD-10 Z30.011–Z30.9 as specified for family-planning services

inv-67: frequency limit

Urinalysis and panels (81000–81003; 80048; 80053; 80061)Each test listed as 'per test' with frequency 'once per day' and must be billed with FP modifier or ICD-10 Z30.*

Example reimbursements80061 (lipid panel) $14.00; 80076 $9.03; 81003 $3.10 (examples from chart)

Billing rulePer-test limits: once per day; chart requires FP modifier or Z30 diagnosis where indicated

Billing, Authorization, and Administrative Review Requirements

Prior Authorization

Prior authorization and review processes

Prior Auth = No for listed procedures.
Some provider-type rows explicitly state: “No, but AUR and PSR process” or similar, indicating post‑payment administrative review may occur.

Documentation Required

Billing requirements tied to authorization/review

When chart comments specify, bill with FP modifier or ICD‑10 DX Z30.011–Z30.9.
AUR/PSR may apply to some entries even when Prior Auth = No.

Billing Rule

Billing modifier and administrative review requirements

Charted requirement: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”
Some rows show “No, but AUR and PSR process applies” or reference PSR/AUR alongside the billing requirement.

Billing Rule

Billing modifier requirement for family planning services

Example statement in multiple rows: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”

Billing Rule

E/M visit billing instructions

E/M codes are billed per visit and typically limited to once per day; 99211 is limited to one per year in some rows.
Chart instructions: “bill with the FP modifier or with the ICD‑10 DX.”

Billing Rule

Billing requirement: FP modifier or ICD-10 Z30 diagnosis

Examples: 99205, 99202–99205, 99395/99396 require FP modifier or Z30.* diagnosis where noted.
Frequency rules (per visit, once per day, one per year) apply as listed in the chart.

Prior Authorization

AUR/PSR notification

Examples: anesthesia codes (00921, 00940) note “No, but AUR and PSR process applies.”
Chart rows frequently include PSR/AUR flags indicating potential post‑payment review.

Billing Rule

FP modifier / ICD-10 Z30.x billing requirement

Examples: A4264 entries and device rows state: “bill with the FP modifier or with the ICD‑10 DX.”
Panel and supply codes list FP or Z30.* as the required billing identifier.

Documentation Required

Administrative review processes

The chart indicates administrative review (AUR) and post‑service review (PSR) apply to many codes; some rows explicitly state Prior Auth = No but note that AUR/PSR still applies to claims.

Multiple code rows include the note: “No, but AUR and PSR process applies.”
PSR/AUR flags are shown per code/provider‑type across the chart.

Documentation Required

Administrative utilization review and payment review (AUR/PSR)

Example: 17110 rows state: “No, but AUR and PSR process applies.”
Rows for other procedures similarly flag AUR/PSR in the comments column.

Billing Rule

Billing requirement — FP modifier or ICD-10 Z30.*

Example chart language: “This provider type must bill with the ICD‑10 DX Z30.011 through Z30.9” or “This provider type must bill with the FP modifier.”
This requirement appears across multiple CPT/HCPCS rows.

Billing Rule

Billing modifier/diagnosis requirement

Common comment in rows: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”

Denial Risk

Prior review / post-service review flags

Monitor for PSR/AUR indicators in the chart comments per code/provider type.
PSR/AUR may result in retrospective review of claims.

Documentation Required

PSR/AUR process notes

Rows explicitly state: “bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”
This instruction appears across procedure, supply and test entries.

Billing Rule

FP modifier / ICD-10 billing requirement

Chart language: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”
Apply the billing identifier at the line level for each applicable CPT/HCPCS code.

Billing Rule

Diagnosis billing requirement / FP modifier instruction

Example: 57061 and 58100 rows state: “This provider type must bill with the ICD‑10 DX Z30.011 through Z30.9.”
Where the chart directs ICD‑10 DX, include the Z30.* diagnosis on the claim.

Documentation Required

AUR and PSR process applies

This flag appears for a variety of procedure and device codes (e.g., colposcopy and destruction procedures).
Expect potential retrospective review when these flags are present.

Billing Rule

Billing requirement — FP modifier or Z30 diagnosis

Typical row note: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”
Apply to procedure, test, device, and visit codes as specified.

Documentation Required

Administrative review processes (AUR / PSR)

Many rows reference AUR and PSR administrative review processes; when those flags appear on code rows, claims may be reviewed post‑service even if prior authorization was not required.

Examples: colposcopy codes (57452) and various biopsy/excision codes include AUR/PSR language.
Follow documentation and billing requirements to reduce risk of administrative review findings.

Documentation Required

Diagnosis linkage requirement

Certain procedure entries explicitly require linkage to an ICD‑10 family‑planning diagnosis (Z30.011–Z30.9) on the claim; include the specified diagnosis when billing those services.

Statement in chart: “This provider type must bill with the ICD‑10 DX Z30.011 through Z30.9.”
Used for procedures such as biopsies and endometrial sampling in specified rows.

Billing Rule

FP modifier or diagnosis required

Common comment: “This provider type must bill with the FP modifier or with the ICD‑10 DX.”
Applies to visits, procedures, tests and device/supply codes shown in the chart.

Billing Rule

Frequency limits

Examples: many procedures are billed “per procedure; once per day.”
Some colposcopy and conization entries list “one per 90 days” or 90‑day intervals.

Documentation Required

ICD-10 billing requirement for family planning services

For many family‑planning services the chart requires billing with ICD‑10 diagnosis codes Z30.011–Z30.9 as the family‑planning diagnosis; include Z30.* when the row specifies it.

Rows state: “This provider type must bill with the ICD‑10 DX Z30.011 through Z30.9.”
Apply across procedure, test and panel entries when specified.

Billing Rule

FP modifier or ICD-10 requirement

The FP modifier or ICD‑10 Z30.011–Z30.9 requirement is repeated throughout the chart for many provider types and CPT/HCPCS codes; follow the specified billing identifier on each row.

Examples: pelvic ultrasound (76857), lab panels (80061) and many procedure codes include this requirement.
The chart typically repeats: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”

Billing Rule

Billing requirement for Family Planning provider type

Panel and test rows (80048, 80061, etc.) state: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”
Apply to lab panels, ultrasounds and other listed services.

Billing Rule

Billing modifier/diagnosis requirement

The chart repeats the billing modifier/diagnosis requirement: include the FP modifier or ICD‑10 Z30.011–Z30.9 on claims for listed provider types and services to align with program billing rules.

Multiple test and panel rows show the instruction: “This provider type must bill with the FP modifier or with the ICD‑10 DX Z30.011 through Z30.9.”

Billing Rule

Billing modifier/diagnosis requirement (repeated)

Entries for panels and urinalysis (81000–81003) repeat the requirement to bill with the FP modifier or ICD‑10 Z30.*.
Consistency across claim lines reduces risk of denial or administrative review.

Program Definitions and Billing Identifiers

inv-95: FP modifier / ICD-10 Z30.011–Z30.9 requirement

FP modifier (program billing modifier)Info modifier required for many provider types when billing Family Planning Services; shown repeatedly in chart entries

ICD-10 family planning diagnosis rangeICD-10 Dx Z30.011 through Z30.9 may be used as alternative billing indicator to the FP modifier

Usage noteRows state: 'This provider type must bill with the FP modifier or with the ICD-10 DX' where applicable

inv-96: AUR and PSR

AUR (Automated Utilization Review)Administrative review process referenced for select codes; chart notes 'AUR process' or 'No, but AUR and PSR process' for some rows

PSR (Post-Service/Provider Specific Review)Post-service review/process (PSR) may apply to some high-cost or procedural entries as noted in chart rows

Provider actionsChart entries indicate when AUR/PSR applies; prior authorization often 'No' but AUR/PSR may still apply

inv-97: FP modifier

FP modifier definition/useBilling modifier indicating Family Planning Services program; required on many provider-type rows in chart

Alternative billingICD-10 Z30.011–Z30.9 may be billed in lieu of FP modifier as noted in many rows

Chart languageEntries state: 'This provider type must bill with the FP modifier or with the ICD-10 DX Z30.011 through Z30.9'

inv-98: AUR and PSR

AUR and PSR processes (administrative review)Described as administrative/utilization review processes applied to certain claims; chart rows reference these as potential review steps

When appliedUsed on select procedure/provider combinations; chart notes 'No, but AUR and PSR process' or 'and PSR process'

Implication for billingClaims may undergo automated or post-payment review even when prior auth is 'No'

inv-99: FP modifier

FP modifier requirement (repeated)Chart repeatedly requires the FP modifier for providers billing family planning services (or alternative Z30 diagnosis)

Explicit chart wordingMany rows state: 'This provider type must bill with the FP modifier or with the ICD-10 DX'

Applies across servicesRequirement appears on preventive, E/M, lab, imaging, and procedure rows as indicated

inv-100: ICD-10 DX Z30.011–Z30.9

ICD-10 Z30.011–Z30.9 rangeRange of family planning diagnosis codes referenced as acceptable billing diagnoses in chart rows

Alternative to FP modifierRows indicate billing with Z30.011–Z30.9 instead of FP modifier is acceptable where noted

Chart examplesMultiple entries state billing 'with the ICD-10 DX Z30.011 through Z30.9'

inv-102: Time-based E/M selection

Time-based E/M selection summaryTotal time on date of encounter may be used for E/M code selection; thresholds shown (e.g., 99205=60min; 99212=10min; 99213=20min; 99214=30min; 99215=40min)

Billing contextWhen time is used for selection, encounter total time must meet or exceed listed minutes per code

Applies to visit rulesThese thresholds are referenced in E/M visit rows for new and established patients