Billing for Family Planning Services
- Billing Guidance is also available in Portable Document Format (PDF, 12KB, 1pg.)
Patient Groups (APG) payment methodology will include a new APG for Contraceptive Management (APG 875). In order for an evaluation and management procedure code to qualify for the new Contraceptive Management APG, a primary diagnosis from the V25 series must appear in the header of the claim. For all other family planning related procedures, when performed in a family planning context, a diagnosis in the V25 series must appear on the claim, but this diagnosis need not be the primary diagnosis. It can be the primary diagnosis or any secondary diagnosis. For procedures 58450 and 58615, Dx code V25.2 must always appear as a diagnosis on the claim since these procedures are always related to family planning. All claims for family planning services must also contain a "Y" in the Family Planning box in the header of the claim. If a payment is made for a family planning procedure, based on a V25 series diagnosis, and the claim does not include a "Y" in the Family Planning box, some or all of the payment for the claim may be subject to recovery under audit. The inappropriate use of a V25 diagnosis could also result in an audit-based recovery. Providers should be sure to follow all appropriate guidelines with respect to using a diagnosis from the V25 series.
The complete list of V25 diagnoses, as well as the procedure codes that are considered to be family planning services, when performed in conjunction with a V25 series diagnosis, will soon be available on the APG Website.