Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter X › Sec2 144-101-X-4 - Limited Family Planning Benefit › Appendix 144-101-X-4.A - APPEAL RIGHTS

Current through 2024-29, July 17, 2024
Billing codes that "prevent or delay pregnancy or
						otherwise control family size" now require an FP modifier in MIHMS.
All Limited Family Planning Benefit claim forms require a
						family planning diagnosis code, with the exceptions of pharmacy and laboratory
						claims, from the approved diagnosis codes listed on the attached Appendix A.
						Claims without an approved family planning diagnosis code will be
						denied.
Unbundling and billing separately for tests included as
						part of a group (profile or panel) that pay at a lower rate is not
						allowed.
As codes or coding conventions change, the codes listed
						in this document will be updated to reflect those changes. Coding updates do
						not indicate a change in coverage policy regarding this benefit.
Diagnosis Codes approved for Limited Family
						Planning Benefit
Category
Code
Description
Cervical cytology
Z11.51
Screen, HPV
R87.810
High-risk HPV DNA test positive
R87.820
Low-risk HPV DNA test positive
Other frequently used
Z01.411
Routine gyn exam, abnormal findings
Z01.419
Routine gyn exam, w/out abnormal findings
Z12.72
Vaginal pap smear
Z12.4
Screening, malignant neoplasm of cervix
Z01.42
Cervical smears to confirm findings following
								  initial abnormal
Z08
Follow-up after treating for malignant
								  neoplasm
Z00.00
General adult medical exam w/out abnormal
								  findings
Z00.01
General adult medical exam w/abnormal
								  findings
Z71.1
Person w/feared health complaint, no
								  diagnosis
Z31.9
Encounter for procreative management
Pregnancy test
Z32.00
Pregnancy test, result unknown
Z32.01
Pregnancy test, result positive
Z32.02
Pregnancy test, result negative
HIV test
Z11.4
Screen, HIV
Z20.6
HIV contact/(suspected) exposure
STD test
Z11.3
Screen, STI
Z11.8
Screening, other infections or parasitis disease
								  (chlamydial)
Z11.59
Screening, other viral diseases
Z12.4
Screening, for malignant neoplasm of
								  cervix
Z20.2
STI contact/(suspected) exposure
Z20.828
Viral disease contact/(suspected) exposure
Z72.51
High risk heterosexual behavior
Z72.52
High risk homosexual behavior
Z72.53
High risk bisexual behavior
Contraceptives
Z30.014
Encounter for initial Rx, IUD
Z30.430
Insertion of IUD
Z30.431
Routine checking of IUD
Z30.432
Removal of IUD
Z30.433
Removal and reinsertion of IUD
T83.32xA
Displacement of IUD, initial encounter
Z30.018
Encounter for initial Rx, other contra
								  (implant)
Z30.49
Surveillance of contra, other (implant)
Z30.013
Encounter for initial Rx, injectable
								  contra
Z30.42
Surveillance of contra, injectable
Z30.011
Encounter for initial RX, oral contra
Z30.41
Surveillance of contra, oral contra
Z30.012
Encounter for Rx, emergency contra
Z30.2
Sterilization
Z98.51
Tubal Ligation status
Z98.52
Vasectomy status
T83.31
Breakdown (mechanical) of UCD
T83.32
Displace of UCD
T83.39
Other mechanical complication of UCD
Additional Family Planning Codes
Z30.018
Encounter for initial Rx, other contra
Z30.019
Encounter for initial Rx, unspecified
								  contra
Z30.09
Encounter for general counseling, contra
Z30.8
Encounter for other contra management
Z30.9
Encounter for contra management,
								  unspecified
Z30.40
Surveillance of contra, unspecified
Z30.02
Counseling, natural family planning
Cervical Abnormalities
R87.610
ASC-USA typical squamous cells of undetermined
								  significance on cytologic smear of cervix
R87.611
ASH-HA typical squamous cells cannot exclude high
								  grade squamous intraepithelial lesion on cytological smear
R87.612
LGSIL Low grade squamous intraepithelial lesion
								  on cytologic smear
R87.613
HGSIL High grade squamous intraepithelial lesion
								  on cytologic smear
R87.619
Unspecified abnormal cytological, cervix
								  uteri
Additional Cervical Abnormalities
C53.0
Malignant neoplasm of endocervix
C53.1
Malignant neoplasm of exocervix
C53.9
Malignant neoplasm of cervix uteri,
								  unspecified
N86
Erosion and ectropion of cervix uteri
D06.0
Carcinoma in situ of endocervix
D06.1
Carcinoma in situ of exocervix
D06.7
Carcinoma in situ of other parts of cervix
D06.9
Carcinoma in situ of cervix, unspecified
N72
Inflammatory disease of cervix uteri
N87.9
Dysplasia of cervix uteri, unspecified
N87.0
Mild cervical dysplasia
N87.1
Moderate cervical dysplasia
N88.0
Leukoplakia of cervix uteri
N88.2
Stricture and stenosis of cervix uteri
N84.1
Polyp of cervix uteri
PID
N73.9
Female pelvic inflammatory disease
N70.11
Chronic salpingitis
N.70.12
Chronic oophoritis
N70.13
Chronic salpingitis and oophoritis
N70.91
Salpingitis, unspecified
N70.92
Oophoritis, unspecified
N70.93
Salpingitis and oophoritis, unspecified
N73.0
Acute parametritis and pelvic celluitis
N73.1
Chronic parametritis and pelvic cellulitis
N73.2
Unspecified parametritis and pelvic
								  cellulitis
N73.3
Female acute pelvic peritonitis
N73.6
Female pelvic peritoneal adhesions
								  (postinfective)
N71.1
Chronic inflammatory disease of uterus
N71.0
Acute inflammatory disease of uteris
Endometriosis
N80.0
Endometriosis of uterus
N80.3
Endometriosis of pelvic peritoneum
N80.6
Endometriosis in cutaneous scar
N80.9
Endometriosis, unspecified
Additional Gyn-Related Diagnosis Codes
N76.0
Acute vaginosis
N76.2
Acute vulvitis
B96.89
Other specified bacterial agents as the cause of
								  other classified
Urethritis
N34.1
Nonspecific urethritis
Herpes
A60.01
Herpesviral infection of penis
A60.04
Herpesviral vulvovaginitis
A60.09
Herpesviral infection of other urogenital
								  tract
A60.9
Anogenital herpes viral infection,
								  unspecified
Genital Warts
B07.9
Viral wart, unspecified
A63.0
Anogenital (venereal) warts
B08.1
Molluscum contagiosum
Syphilis
A51.0
Primary genital syphilis
A51.31
Condyloma latum
A51.39
Other secondary syphilis of skin
A51.5
Early syphilis, latent
A52.11
Tabes dorsalis
A52.16
Charcot's arthropathy (tabetic)
A52.8
Late syphilis, latent
A52.9
Late syphilis, unspecified
A53.0
Latent syphilis, unspecified as early or
								  late
Epididymitis
N45.1
Epididymitis
Menstrual
N91.0
Primary amenorrhea
N91.1
Secondary amenorrhea
N91.2
Amenorrhea, unspecified
N91.3
Primary oligomenorrhea
N91.4
Secondary oligomenorrhea
N91.5
Oligomenorrhea, unspecified
N92.0
Excessive/frequent menstruation w/regular
								  cycle
N92.5
Other specified irregular menstruation
N92.6
Irregular menstruation, unspecified
N94.1
Dyspareunia
N94.3
Premenstrual tension syndrome
N94.4
Primary dysmenorrhea
N94.5
Secondary dysmenorrhea
N94.6
Dysmenorrhea, unspecified
Chlamydial Infections
A56.00
Chlamydial infection, lower GU tract,
								  unspecified
A56.01
Chlamydial cystitis and urethritis
A56.02
Chlamydial vulvovaginitis
A56.09
Other chlamydial infection of lower GU
								  tract
A56.11
Chlamydial female PID
Gonococcal Infections
A54.24
Gonococcal female PID
A54.29
Other gonococcal GU infections
A54.00
Gonococcal infection, lower GU tract,
								  unspecified
A54.02
Gonococcal vulvovaginitis, unspecified
A54.09
Other gonococcal infection of lower GU
								  tract
A54.01
Gonococcal cystitis and urethritis,
								  unspecified
A54.1
Gonococcal infection of lower GU tract
								  w/abscess
A54.22
Gonococcal prostatitis
A54.23
Gonococcal infection, other male genital
								  organs
A54.03
Gonococcal cervicitis, unspecified
A54.21
Gonococcal infection of kidney and ureter
A54.29
Other gonococcal GU infections
A54.5
Conococcal pharyngitis
A54.6
Gonococcal infection of anus and rectum
Trichomoniasis
A59.01
Trichomonal vulvovaginitis
A59.02
Trichomonal prostatitis
A59.03
Trichomonal cystitis and urethritis
Scabies & Pubic Lice
B86
Scabies
B85.3
Phthiriasis (Public Lice)
Breast-Related
N64.4
Mastodynia
N63
Unspecified lump in breast
N60.19
Diffuse cystic mastopathy of breast,
								  unspecified
N60.12
Diffuse cystic mastopathy of left breast
N60.11
Diffuse cystic mastopathy of right breast
Other
Z22.4
Carrier of infections with a predominantly sexual
								  mode of transmission
Z22.50
Carrier of unspecified viral hepatitis
Procedure Codes for Limited Family Planning
						Benefit
For rates, see the Department's rate-setting website:
						https://mainecare.maine.gov/Provider%20Fee%20Schedules
Procedure Code
Description
11976
Removal, implantable contraceptive
								  capsules
11981
Insertion, non-biodegradable drug delivery
								  implant
11982
Removal, non-biodegradable drug delivery
								  implant
11983
Removal and reinsertion, non-biodegradable drug
								  delivery implant
17110
Destruction (eg., laser surgery, electrosurgery,
								  cryosurgery, chemosurgery, surgical currettement), of benign lesions other than
								  skin tags or cutaneous vascular proliferative lesions; up to 14 lesions
17111
Destruction (eg, laser surgery, electrosurgery,
								  cryosurgery, chemosurgery, surgical currettement), of benign lesions other than
								  skin tags or cutaneous vascular proliferative lesions; 15 or more
								  lesions
36415
Collection of venous blood by venipuncture
36416
Collection of capillary blood specimen (eg.,
								  finger, heel, earstick)
46900
Destruction of lesion(s), anus, simple;
								  chemical
46910
Destruction of lesion(s),
								  electrodesiccation
46916
Destruction of lesion(s), cryosurgery
46922
Destruction of lesion(s), surgical
								  excision
46924
Destruction of lesion(s), anus, extensive
54050
Destruction of lesion(s); penis (e.g. condyloma,
								  papilloma, molluscum contagiousum, herpetic vesicle), simple; chemical
54055
Destruction of lesion(s); penis (e.g. condyloma,
								  papilloma, molluscum contagiousum, herpetic vesicle), simple;
								  electrodessication
54056
Destruction of lesion(s); penis (e.g. condyloma,
								  papilloma, molluscum contagiousum, herpetic vesicle), simple;
								  cryosurgery
54057
Destruction of lesion(s); penis (e.g. condyloma,
								  papilloma, molluscum contagiousum, herpetic vesicle), simple; laser
54060
Destruction of lesion(s); penis (e.g. condyloma,
								  papilloma, molluscum contagiousum, herpetic vesicle), simple; surgical
								  excision
54065
Destruction of lesion(s); penis (e.g. condyloma,
								  papilloma, molluscum contagiousum, herpetic vesicle), extensive; (e.g. laser
								  surgery, electrosurgery, cryosurgery, chemosurgery)
54100
Biopsy penis separate procedure
55200
Vasotomy cannulization w/wo vas inc uni/bi
								  spx
55250
Vasectomy, unilateral or bilateral (separate
								  procedure), including postoperative semen examination(s)
56405
Incision and drainage of vulva or perineal
								  abscess
56420
Incision and drainage of Bartholin's gland
								  abscess
55450
Ligation (percutaneous) of vas deferens,
								  unilateral or bilateral (separate procedure)
56501
Destruction of lesion(s) vulva; simple (laser
								  surgery, electrosurgery, cryosurgery, chemosurgery)
56515
Destruction of lesion(s); vulva; extensive (e.g.
								  laser surgery, electrosurgery, cryosurgery, chemosurgery)
56605
Biopsy of vulva or perineum (separate procedure);
								  one lesion
56606
Biopsy of vulva or perineum (separate procedure);
								  each separate additional lesion (List separately in addition to the 56605
								  billing code for primary procedure.)
56820
Colposcopy of the vulva;
56821
Colposcopy of the vulva; with biopsy(s)
57061
Destruction of vaginal lesion(s); simple (laser
								  surgery, electrosurgery, cryosurgery, chemosurgery)
57065
Destruction of vaginal lesion(s); extensive
								  (laser surgery, electrosurgery, cryosurgery, chemosurgery)
57100
Biopsy vaginal mucosa simple
57105
Biopsy vaginal mucosa extensive
57170
Diaphragm or cervical cap fitting with
								  instructions
57452
Colposcopy of the cervix including upper/adjacent
								  vagina
57454
Colposcopy with biopsy(s) of the cervix and
								  endocervical curettage
57500
Biopsy of cervix, single or multiple, or local
								  excision of lesion, with or without fulguration (separate procedure)
57505
Endocervical curettage (not done as part of a
								  dilation and curettage)
57510
Cautery cervix electro/thermal
57511
Cautery of cervix; electro or thermal;
								  cryocautery, initial or repeat
57513
Cautery cervix laser ablation
57800
Dilation of cervical canal; instrumental
								  (separate procedure)
58100
Endometrial sampling (biopsy) with or without
								  endocervical sampling (biopsy), without cervical dilation, any method (separate
								  procedure)
58110
Endometrial sampling (biopsy) performed in
								  conjunction with colposcopy (list separately in addition to code for primary
								  procedure)
[Use 58110 in conjunction with
								  57452-57454.]
58120
Dilation & curettage diagnostic and/or
								  therapeutic (nonobstetric)
58300
Insertion of intrauterine device (IUD)
58301
Removal of intrauterine device (IUD)
58600
Ligation or transection of fallopian tube(s),
								  abdominal or vaginal approach, unilateral or bilateral
58615
Occlusion of fallopian tube(s) by device (eg,
								  band, clip, Falope ring) vaginal or suprapublic approach
58670
Tubal ligation by laparoscopic surgery with
								  fulguration of oviducts (with or without transection)
58671
Tubal ligation by laparoscopic surgery with
								  occlusion of oviducts by device (eg, band, clip, or Falope ring)
64435
Injection, anesthetic agent paracervical
								  (uterine) nerve
72190
Radiologic examination, pelvis, complete, minimum
								  3 views
74000
Radiologic examination, abdomen; single
								  anteroposterior view
74010
Radiologic examination, abdomen, anteroposterior
								  and additional oblique and cone views
74740
Hysterosalpinography radiological supervision and
								  interpretation
76830
Ultrasound transvaginal
76831
Echo exam uterus
76856
Ultrasound, pelvic (nonobstretic), real time with
								  image documentation; complete
76857
Ultrasound, pelvic (nonobstretic), real time with
								  image documentation, limited or follow-up (eg, for follicles)
81000
Urinalysis, by dip stick or tablet reagent
81001
Urinalysis; automated with microscopy
81002
Urinalysis, non-automated without
								  microscopy
81003
Urinalysis, automated without microscopy
81005
Urinalysis; qualitative or semiquantitative
								  except immunoassays
81007
Urine screen for bacteria
81025
Urine pregnancy test, by visual color comparison
								  methods
82120
Amines vaginal fluid qualitative
85013
Blood count; spun microhematocrit
85014
Blood count; other than spun hematocrit
85018
Hemoglobin (Hgb)(To bill this code providers must
								  have their current CLIA-waiver certificates on file with MaineCare and update
								  their provider enrollment with the Department.)
85025
Complete CBC with auto diff WBC
85027
Blood count, complete (CBC), automated (Hgb, Hct,
								  RBC, WVC and platelet count)
86592
Syphilis test, non-treponemal antibody;
								  qualitative
86593
Syphilis test, quantitative
86631
Chlamydia test
86632
Chlamydia, IgM
86689
HTLV or HIV antibody, confirmatory test
86694
Herpes simplex, non-specific type test
86695
Herpes simplex, type 1
86696
Herpes simplex, type 2
86701
HIV-1
86702
HIV-2
86703
HIV-1 and HIV-2, single assay (ex. Oraquick
								  Advance Rapid 1/2. (If positive result, providers must recommend Western Blot
								  confirmatory testing and collect a sample, blood or saliva, during the same
								  encounter to send to an outside professional lab for testing. Prepaid Kits to
								  collect the sample are to be purchased from the Maine Center for Disease
								  Control and Prevention, Health and Environmental Testing Laboratory in
								  accordance with
MaineCare Benefits Manual
, Section 90.04-2
								  4).
87081
Culture, presumptive, pathogenic organisms,
								  screening only
87086
Culture, bacterial; quantitative colony count,
								  urine
87110
Culture, chlamydia, any source
87207
Smear, primary source, with interpretation,
								  special stain for inclusion bodies or parasites (eg, malaria, coccidian,
								  microsporidia, trypanosomes, herpes viruses)
87210
Smear, primary source with interpretation; Gram
								  or Giemsa stain for bacteria, fungi, or cell types; wet mount for infectious
								  agents (e.g. saline, India ink, KOH preps)
87270
Infectious agent antigen detection by enzyme
								  immunofluorescent technique; adenovirus; Chlamydia trachomatis
87273
Herpes simplex virus type 2
87274
Herpes simplex virus, type 1
87285
Treponema pallidum
87320
Infectious agent antigen detective by enzyme
								  immunoassay technique; Chlamydia trachomatis
87340
Hepatitis B surface antigen
87390
HIV-1
87391
HIV-2
87490
Infectious agent detection by nucleic acid (DNA
								  or RNA); Chlamydia trachomatis, direct probe technique
87491
Chlamydia trachomatis, amplified probe
								  technique
87492
Chlamydia trachomatis, quantification
87510
Gardnerella vaginalis direct probe
								  technique
87511
Gardnerella vaginalis amplified probe
								  technique
87528
Herpes simplex visu, direct probe
								  technique
87529
Herpes simplex virus, amplified probe
								  technique
87530
Herpes simplex virus, quantification
87534
HIV-1, direct probe technique
87535
HIV-1, amplified probe technique, includes
								  reverse transcription when performed
87536
HIV-1, quantification, includes reverse
								  transcription when performed
87537
HIV-2, direct probe technique
87538
HIV-2, amplified probe technique
87539
HIV-2, quantification
87590
Neisseria gonorrhoeae, direct probe
								  technique
87591
Neisseria gonorrhoeae, amplified probe
								  technique
87592
Neisseria gonorrhoeae, quantification
87624
Human Papillomavirus (HPV), high-risk types
87810
Infectious agent detection by immunoassay with
								  direct optical observation; Chlamydia trachomatis
87850
Neisseria gonorrhea
88141
Cytopathology, cervical or vaginal (any reporting
								  system), requiring interpretation by physician
88142
Cytopathology, cervical or vaginal (any reporting
								  system), collected in preservative fluid, automated thin layer preparation;
								  manual screening under physician supervision
88150
Cytopathology, slides, cervical or vaginal;
								  manual screening under physician supervision
88164
Cytopathology, slides, cervical or vaginal
88165
Cytopathology, slides, cervical or vaginal
88175
Cytopathology, cervical or vaginal, collected in
								  preservative fluid, automated thin layer preparation; with screening by
								  automated system and manual rescreening or review, under physician
								  supervision
88302
Surgical pathology, gross and nicroscopic
								  examination
90471
Immunization administration (includes
								  percutaneous, intradermal, subcutaneous, or intramuscular injections); 1
								  vaccine (single or combination vaccine/toxoid)
90472
Each additional vaccine (single or combination
								  vaccine/toxoid)
90636
Hepatitis A and hepatitis B vaccine (HepA-HepB),
								  adult dosage for intramuscular use
90649
Human Papilloma Virus (HPV) vaccine types 6, 11,
								  16, 18 (quadrivalent), 3 dose schedule, for intramuscular use
90651
Human Papilloma Virus (HPV) vaccine types 6, 11,
								  16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 3 dose schedule for
								  intramuscular use.
93000
Electrocardiogram, routine ECG with at least 12
								  leads; with interpretation and report (sterilization pre-op only)
93010
Electrocardiogram, routine ECG with at least 12
								  leads; interpretation and report only (sterilization pre-op only)
96372
Therapeutic, prophylactic, or diagnostic
								  injection(specify substance or drug); subcutaneous or intramuscular
99201
Office or other outpatient visit for the
								  evaluation and management of a new patient, which requires these three (3) key
								  components: a problem focused history; a problem focused examination; and
								  straightforward medical decision making. Counseling and/or coordination of care
								  with other providers or agencies are provided consistent with the nature of the
								  problem(s) and the patient's and/or family's needs. Usually, the presenting
								  problem(s) are self-limited or minor. Physicians typically spend ten (10)
								  minutes face-to-face with the patient and/or family. (Physician assistants and
								  nurse practitioners may also perform these services within the scope of their
								  licensure.)
99202
Office or other outpatient visit for the
								  evaluation and management of a new patient, which requires these three (3) key
								  components: an expanded problem focused history; an expanded problem focused
								  examination; and straightforward medical decision making. Counseling and/or
								  coordination of care with other providers or agencies are provided consistent
								  with the nature of the problem(s) and the patient's and/or family's needs.
								  Usually, the presenting problem(s) are of low to moderate severity. Physicians
								  typically spend twenty (20) minutes face-to-face with the patient and/or
								  family.
99203
Office or other outpatient visit for the
								  evaluation and management of a new patient, which requires these three (3) key
								  components: a detailed history; a detailed examination; and medical decision
								  making of low complexity. Counseling and/or coordination of care with other
								  providers or agencies are provided consistent with the nature of the problem(s)
								  and the patient's and/or family's needs. Usually, the presenting problem(s) are
								  of moderate severity. Physicians typically spend thirty (30) minutes
								  face-to-face with the patient and/or family.
99204
Office or other outpatient visit for the
								  evaluation and management of a new patient, which requires these three (3) key
								  components: a comprehensive history; a comprehensive examination; and medical
								  decision making of moderate complexity. Counseling and/or coordination of care
								  with other providers or agencies are provided consistent with the nature of the
								  problem(s) and the patient's and/or family's needs. Usually, the presenting
								  problem(s) are of moderate to high severity. Physicians typically spend
								  forty-five (45) minutes face-to-face with the patient and/or family.
99205
Office or other outpatient visit for the
								  evaluation and management of a new patient, which requires these three (3) key
								  components: a comprehensive history; a comprehensive examination; and medical
								  decision making of high complexity. Counseling and/or coordination of care with
								  other providers or agencies are provided consistent with the nature of the
								  problem(s) and the patient's and/or family's needs. Usually, the presenting
								  problem(s) are of moderate to high severity. Physicians typically spend sixty
								  (60) minutes face-to-face with the patient and/or family.
99211
Office or other outpatient visit for the
								  evaluation and management of an established patient that may not require the
								  presence of a physician. Usually, the presenting problem(s) are minimal.
								  Typically, five (5) minutes are spent performing or supervising these
								  services.
99212
Office or other outpatient visit for the
								  evaluation and management of an established patient, which requires at least
								  two (2) of these three (3) key components: a problem focused history; a problem
								  focused examination; and straightforward medical decision making. Counseling
								  and/or coordination of care with other providers or agencies are provided
								  consistent with the nature of the problem(s) and the patient's and/or family's
								  needs. Usually, the presenting problem(s) are self-limited or minor. Physicians
								  typically spend ten (10) minutes face-to-face with the patient and/or
								  family.
99213
Office or other outpatient visit for the
								  evaluation and management of an established patient, which requires at least
								  two (2) of these three (3) key components: an expanded problem focused history;
								  an expanded problem focused examination; and medical decision making of low
								  complexity. Counseling and/or coordination of care with other providers or
								  agencies are provided consistent with the nature of the problem(s) and the
								  patient's and/or family's needs. Usually, the presenting problem(s) are of low
								  to moderate severity. Physicians typically spend fifteen (15) minutes
								  face-to-face with the patient and/or family.
99214
Office or other outpatient visit for the
								  evaluation and management of an established patient, which requires at least
								  two (2) of these three (3) key components: a detailed history; a detailed
								  examination; and medical decision making of moderate complexity. Counseling
								  and/or coordination of care with other providers or agencies are provided
								  consistent with the nature of the problem(s) and the patient's and/or family's
								  needs. Usually, the presenting problem(s) are of moderate to high severity.
								  Physicians typically spend twenty-five (25) minutes face-to-face with the
								  patient and/or family.
99215
Office or other outpatient visit for the
								  evaluation and management of an established patient, which requires at least
								  two (2) of these three (3) key components: a comprehensive history; a
								  comprehensive examination; and medical decision making of high complexity.
								  Counseling and/or coordination of care with other providers or agencies are
								  provided consistent with the nature of the problem(s) and the patient's and/or
								  family's needs. Usually, the presenting problem(s) are of moderate to high
								  severity. Physicians typically spend forty (40) minutes face-to-face with the
								  patient and/or family.
99384
Initial comprehensive preventative medicine
								  evaluation and management of an individual including an age and gender
								  appropriate history, examination, counseling/anticipatory guidance/risk factor
								  reduction interventions, and the ordering of laboratory/diagnostic procedures,
								  new patient, adolescent (age 12 through 17 years). (All providers of these
								  services must meet all
MaineCare Benefits Manual
, Section 94
								  "Early, Periodic, Screening, Diagnostic and Treatment (EPSDT)" periodicity
								  requirements for MaineCare members up to their twenty-first (21)
								  birthday.)
99385
Initial comprehensive preventative medicine
								  evaluation and management of an individual including an age and gender
								  appropriate history, examination, counseling/anticipatory guidance/risk factor
								  reduction interventions, and the ordering of laboratory/diagnostic procedures,
								  new patient, adolescent age 18-39 years. (All providers of these services must
								  meet all
MaineCare Benefits Manual
, Section 94 "Early,
								  Periodic, Screening, Diagnostic and Treatment (EPSDT)" periodicity requirements
								  for MaineCare members up to their twenty-first (21) birthday.)
99386
Initial comprehensive preventative medicine
								  evaluation and management of an individual including an age and gender
								  appropriate history, examination, counseling/anticipatory guidance/risk factor
								  reduction interventions, and the ordering of laboratory/diagnostic procedures,
								  new patient, adolescent (age 40-64)
99387
Initial comprehensive preventative medicine
								  evaluation and management of an individual including an age and gender
								  appropriate history, examination, counseling/anticipatory guidance/risk factor
								  reduction interventions, and the ordering of laboratory/diagnostic procedures,
								  new patient, adolescent (65 years and older)
99394
Periodic comprehensive preventative medicine
								  reevaluation and management of an individual including an age and gender
								  appropriate history, examination, counseling/anticipatory guidance/risk factor
								  reduction interventions, and the ordering of laboratory diagnostic procedures,
								  established patient; adolescent (age 12 through 17 years). (All providers of
								  these services must meet all
MaineCare Benefits Manual
,
								  Section 94 E arly, Periodic, Screening, Diagnostic and Treatment (EPSDT)
								  periodicity requirements for MaineCare members up to their twenty-first (21)
								  birthday.)
99395
Periodic comprehensive preventive medicine
								  reevaluation and management of an individual including an age and gender
								  appropriate history, examination, counseling/anticipatory guidance/risk factor
								  reduction interventions and the ordering of appropriate laboratory/diagnostic
								  procedures, established patient; age 18-39 years. (All providers of these
								  services must meet all
MaineCare Benefits Manual
, Section 94 E
								  arly, Periodic, Screening, Diagnostic and Treatment (EPSDT) periodicity
								  requirements for MaineCare members up to their twenty-first (21)
								  birthday.)
99396
Periodic comprehensive preventive medicine
								  reevaluation and management of an individual including an age and gender
								  appropriate history, examination, counseling/anticipatory guidance/risk factor
								  reduction interventions and the ordering of appropriate laboratory/diagnostic
								  procedures, established patient; 40-64 years
99397
Periodic comprehensive preventative medicine
								  reevaluation and management of an individual including an age and gender
								  appropriate history, examination, counseling/anticipatory guidance/risk factor
								  reduction interventions, and the ordering of laboratory diagnostic procedures,
								  established patient; adolescent (65 years and older)
99401
Preventative medicine counseling and/or risk
								  factor reduction intervention(s) provided to an individual (separate
								  procedure); approximately 15 minutes (Family planning professionals and other
								  qualified staff may provide.]
99402
Preventative medicine counseling and/or risk
								  factor reduction intervention(s) provided to an individual (separate
								  procedure); approximately 30 minutes (Family planning professionals and other
								  qualified staff may provide.]
99403
Preventative medicine counseling and/or risk
								  factor reduction intervention(s) provided to an individual (separate
								  procedure); approximately 45 minutes (Family planning professionals and other
								  qualified staff may provide.]
A4266
Diaphragm for contraceptive use
A4267
Contraceptive supply, condom, male, each
A4268
Contraceptive supply, condom, female, each
A4269
Contraceptive supply, spermicide (e.g., foam,
								  gel) each
J0558
Penicillin G benzathine/procaine injection,
								  100,000 units
J0561
Penicillin G benzathine injection, 100,000
								  units
J0690
Injection, cefazolin sodium, 500 mg
J0694
Injection, cefoxitin sodium, 1 g
J0696
Injection, ceftriaxone sodium, per 250 mg
J0697
Injection, sterile cefuroximr sodium, per 750
								  mg
J0698
Cefotaxime sodium, per g
J0710
Injection, cephapirin sodium, up to 1 g
J0715
Injection, ceftizoxime sodium, per 500 mg
J1050
Injection, medroxyprogesterone acetate, 1
								  mg
J1850
Injection, kanamycin sulfate, up to 75 mg
J1890
Injection, cephalothin sodium, up to 1 g
J3000
Injection, streptomycin, up to 1 g
J3260
Injection, tobramycin sulfate, up to 80 mg
J3320
Injection, spectinomycin dihydrochloride, up to 2
								  g
J3370
Injection, vancomycin HC1, 500 mg
J7297
Levonorgestrel-releasing intrauterine
								  contraceptive system, 52 mg, 3 yr. duration (Liletta)
J7298
Levonorgestrel-releasing intrauterine
								  contraceptive system, 52 mg, 5 yr. duration (Mirena)
J7300
Intrauterine copper contraceptive (Paragard
								  T3880A)
J7301
Levonorgestrel-releasing intrauterine
								  contraceptive system, 13.5 mg (Skyla)
J7303
Contraceptive Supply, hormone containing vaginal
								  ring, each
J7304
Contraceptive Supply, hormone containing patch,
								  each (not on UCR)
J7307
Etongestrel (contraceptive) implant system,
								  including implant and supplies (Implanon and Nexplanon)
S4993
Contraceptive pills for birth control