Family Planning Billing Guide

1 Washington Apple Health (Medicaid) Family Planning Billing Guide Including: Reproductive Health Services, Family Planning Only Pregnancy Related program and Family Planning Only program October 1, 2021 CPT codes and descriptions only are copyright 2020 American Medical Association. 2 | Family Planning Billing Guide Disclaimer Every effort has been made to ensure this Guide s accuracy. If an actual or apparent conflict between this document and a Health Care Authority (HCA) rule arises, the HCA rule applies. Billing guides are updated on a regular basis. Due to the nature of content change on the internet, we do not fix broken links in past guides. If you find a broken link, please check the most recent version of the Guide . If this is the most recent Guide , please notify us at About this guide1 This publication takes effect October 1, 2021, and supersedes earlier Billing guides to this program.

2 This Billing Guide includes Billing information for the following programs: Reproductive Health Services Family Planning Only Pregnancy Related Family Planning Only HCA is committed to providing equal access to our services. If you need an accommodation or require documents in another format, please call 1-800-562-3022. People who have hearing or speech disabilities, please call 711 for relay services. Washington Apple Health means the public health insurance programs for eligible Washington residents. Washington Apple Health is the name used in Washington State for Medicaid, the children s health insurance program (CHIP), and state-only funded health care programs. Washington Apple Health is administered by HCA. Refer also to HCA s ProviderOne Billing and Resource Guide for valuable information to help you conduct business with HCA.

3 How can I get HCA Apple Health provider documents? To access providers alerts, go to HCA s provider alerts webpage. To access provider documents, go to HCA s provider Billing guides and fee schedules webpage. 1 This publication is a Billing instruction. CPT codes and descriptions only are copyright 2020 American Medical Association. 3 | Family Planning Billing Guide Where can I download HCA forms? To download an HCA form, see HCA s Forms & Publications webpage. Type only the form number into the Search box (Example: 13-835). Copyright disclosure Current Procedural Terminology (CPT) copyright 2020 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use.

4 The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. What has changed? Subject Change Reason for Change Entire Guide Updated language to gender-neutral To reflect current policy. Sexual and Reproductive Health Program (SRHP) Fee Schedule Added new section To comply with ESSB 5092 Sec. 211 (36) budget proviso What services are covered under the Family Planning Only programs Updated language from Intravaginal contraceptive to monthly intravaginal contraceptive Added language Yearly intravaginal contraceptive ring Updated language from Male and female condoms to external and internal condoms Effective October 1, 2021, the monthly and yearly vaginal rings have their own procedure codes.

5 Coverage Table Updated short descriptions throughout To align with the 2021 CPT short description list CPT codes and descriptions only are copyright 2020 American Medical Association. 4 | Family Planning Billing Guide Subject Change Reason for Change Coverage table Comprehensive prevention Family Planning visit Updated comments To use gender-neutral terminology Laboratory table Removed CPT code 88154 Code termed January 1, 2018 and is no longer on the fee schedule STD/STI treatment Updated the STI medication list To reflect the Centers for Disease Control (CDC) updated STI treatment guidelines for 2021 340B dispensing fee Removed HCPCs code J7303 and added codes J7295 and J7294 Both types of birth control vaginal rings shared HCPCs code J7 303. They have each been assigned their own procedure codes effective October 1, 2021.

6 Contraceptives coverage table Added HCPCs codes J7295 and J7294 and removed J7303 Both types of birth control vaginal rings shared HCPCs code J7303. They have each been assigned their own procedure codes effective October 1, 2021. Mammograms Updated language to be more general and refer to the Physician Billing Guide The mammogram information is listed in the Physician-Related/Professional Services Billing Guide . CPT codes and descriptions only are copyright 2020 American Medical Association. 5 | Family Planning Billing Guide Table of Contents Resources Available .. 7 Definitions .. 8 General .. 10 How do I verify a client s eligibility? .. 10 Verifying eligibility is a two-step process: .. 10 Are clients enrolled in an HCA-contracted managed care organization (MCO) eligible? .. 11 Managed care enrollment.

7 11 Clients who are not enrolled in an HCA-contracted managed care plan for physical health services .. 12 Integrated managed care .. 12 Integrated Apple Health Foster Care (AHFC) .. 13 Fee-for-service Apple Health Foster Care .. 14 Provider Requirements .. 14 Confidentiality, consent, and release of information .. 14 Nationally recognized clinical 14 How do I bill claims electronically? .. 15 How do providers bill for managed care services? .. 15 How do providers who participate in the 340B drug pricing program bill for drugs and dispensing fees? .. 16 Sexual and Reproductive Health Program (SRHP) Fee Schedule .. 17 SRHP fee schedule requirements .. 17 Federally Qualified Health Center (FQHC) SRHP Billing .. 17 Reproductive Health Services .. 18 What are reproductive health services? .. 18 Who is eligible for reproductive health services?

8 18 Managed care clients .. 18 Self-referral for managed care clients .. 18 Limited coverage .. 19 Where can Washington Apple Health clients receive reproductive health services? .. 19 What are the requirements for providers? .. 19 What reproductive health services are covered? .. 20 What reproductive health services are not covered? .. 21 What fee does HCA pay? .. 21 Family Planning Only Programs .. 22 CPT codes and descriptions only are copyright 2020 American Medical Association. 6 | Family Planning Billing Guide What is the purpose of the Family Planning Only programs? .. 22 Who is eligible?.. 22 Family Planning Only Pregnancy Related program .. 22 Family Planning Only program .. 22 What services are covered under the Family Planning Only programs? .. 24 Complications from contraceptive methods.

9 25 What drugs and supplies are covered under the Family Planning Only programs? .. 26 Coverage table .. 26 Office visits for Family Planning surveillance and follow-up visits .. 27 Comprehensive prevention Family Planning visit .. 27 Contraceptives .. 28 Radiology services .. 28 Laboratory services .. 28 STD/STI treatment .. 30 What does HCA pay for? .. 32 What fee does HCA pay? .. 32 What does HCA not pay for? .. 32 Billing for third-party liability and good cause .. 33 What are the requirements for Family Planning Only programs providers? . 34 Documentation requirements .. 34 Provider requirements specific to the Family Planning Only program .. 34 What contraceptives does HCA cover? .. 35 Hormonal contraceptive prescribing .. 35 Hormonal contraceptives filled at the pharmacy .. 37 Hormonal contraceptives dispensed from a Family Planning clinic.

10 37 Immediate postpartum Long-Acting Reversible contraceptive (LARC) insertion .. 38 Contraceptives coverage table .. 38 Prescription contraceptives .. 38 Nonprescription over-the-counter (OTC) contraceptives .. 42 Nondrug contraceptive supplies (natural Family Planning ) .. 43 Appendix A .. 44 Clinic visit scenarios for Family Planning Only programs .. 44 Appendix B .. 46 Frequently asked questions .. 46 CPT codes and descriptions only are copyright 2020 American Medical Association. 7 | Family Planning Billing Guide Resources Available Topic Resource Information about reproductive health services, the Family Planning Only and Family Planning Only Pregnancy Related programs Contact the Billers, providers, and partners Contact us webpage. Contact the Family Planning Program at: For additional Billing guidance See the following Billing guides: Outpatient Hospital Billing Guide Physician-Related/Professional Services Billing Guide Professional Administered Drugs Fee Schedule Family Planning Only application form, HCA 13-781 (8/20) (for clients) See Where can I download HCA forms?