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 III - Allowances for Services › Section 144-101-III-30 - Family Planning Agency Services

Current through 2024-29, July 17, 2024
Federal regulations require the Department to utilize
					 certain medical data billing code sets.
					 45 C.F.R.
					 §162.1000. Each code set is valid within
					 the dates specified by the organization responsible for maintaining that code
					 set. 45 C.F.R. §1011. Approximately quarterly, the Centers for Medicare
					 and Medicaid Services (CMS) issues to States a Healthcare Common Procedure
					 Coding System Transaction List that includes additions to and deletions from
					 this schedule of billing codes. Providers will be notified of all such
					 additions and deletions through the publication of notices of reimbursement
					 methodology change, pursuant to
					 42
					 C.F.R. §447.205, through regular mail,
					 by a revised Allowances for Family Planning Agency Services, or by revised
					 billing instructions, as appropriate.
Please note: As of the 7/1/11 effective date of this
					 rule, Family Planning agencies will be reimbursed at the same fee for service
					 rates as other providers of these services, including Section 90, Physicians
					 Services where applicable . All information below is current on the effective
					 date of this rule. Subsequent to the effective date, the rates in effect and
					 other information will be posted and available at:
www.maine.gov/dhhs/audit/rate-setting/index.shtml
.
** MaineCare payment under these codes is dependent
					 upon approval by the Centers for Medicare and Medicaid of a state plan
					 amendment.
Billing codes that "prevent or delay pregnancy or
					 otherwise control family size" now require an FP modifier in MIHMS. The
					 "Modifier" column below is listed for guidance only. Professional judgment
					 should be used in determining whether the service being provided is "to prevent
					 or delay pregnancy or otherwise control family size" and the modifier
					 appropriately applied.
Procedure Code
Description
Modifier
Rate
11976
Removal, implantable contraceptive capsules
FP
$87.91*
11981**
Insertion, non-biodegradable drug delivery implant
FP
80.56
54050
Destruction of lesion(s); penis (e.g. condyloma,
								papilloma, molluscum contagiousum, herpetic vesicle), simple; chemical
No
$78.12*
54055
Destruction of lesion(s); penis (e.g. condyloma,
								papilloma, molluscum contagiousum, herpetic vesicle), simple;
								electrodessication
No
$74.66*
54056
Destruction of lesion(s); penis (e.g. condyloma,
								papilloma, molluscum contagiousum, herpetic vesicle), simple; cryosurgery
No
$81.48*
54057
Destruction of lesion(s); penis (e.g. condyloma,
								papilloma, molluscum contagiousum, herpetic vesicle), simple; laser
No
$71.81*
54060
Destruction of lesion(s); penis (e.g. condyloma,
								papilloma, molluscum contagiousum, herpetic vesicle), simple; surgical excision
No
$121.18*
54065
Destruction of lesion(s); penis (e.g. condyloma,
								papilloma, molluscum contagiousum, herpetic vesicle), extensive; (e.g. laser
								surgery, electrosurgery, cryosurgery, chemosurgery)
No
$139.32*
56501
Destruction of lesion(s) vulva; simple (laser
								surgery, electrosurgery, cryosurgery, chemosurgery)
No
$79.25*
56515
Destruction of lesion(s); vulva; extensive (e.g.
								laser surgery, electrosurgery, cryosurgery, chemosurgery)
No
$138.60*
56605
Biopsy of vulva or perineum (separate procedure);
								one lesion
No
$51.25*
56606
Biopsy of vulva or perineum (separate procedure);
								each separate additional lesion (List separately in addition to the 56605
								billing code for primary procedure.)
No
$23.77*
56820
Colposcopy of the vulva;
No
$68.06*
56821
Colposcopy of the vulva; with biopsy (s)
No
$91.16*
57061
Destruction of vaginal lesion(s); simple (laser
								surgery, electrosurgery, cryosurgery, chemosurgery)
No
$68.87*
57065
Destruction of vaginal lesion(s); extensive (laser
								surgery, electrosurgery, cryosurgery, chemosurgery)
No
$117.82*
57170
Diaphragm or cervical cap fitting with instructions
FP
$46.38*
57452
Colposcopy of the cervix including upper/adjacent
								vagina
No
$67.39*
57454
Colposcopy with biopsy(s) of the cervix and
								endocervical curettage
No
$95.67*
57500
Biopsy of cervix, single or multiple, or local
								excision of lesion, with or without fulguration (separate procedure)
No
$80.03*
57511
Cautery of cervix; electro or thermal; cryocautery,
								initial or repeat
No
$88.98*
58100
Endometrial sampling (biopsy) with or without
								endocervical sampling (biopsy), without cervical dilation, any method (separate
								procedure)
No
$67.91*
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.]
No
$30.48*
58300
Insertion of intrauterine device (IUD)
FP
$43.27*
58301
Removal of intrauterine device (IUD)
FP
$59.18*
81025
Urine pregnancy test, by visual color comparison
								methods
FP
$9.83*
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.)
$2.88*
86703
HIV-1 and HIV-2, single assay (ex. Oraquick Advance
								Rapid !4 (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).
No
$39.34*
87086
Culture, bacterial; quantitative colony count, urine
								(To bill this code providers must have their current CLIA-waiver certificates
								on file with MaineCare and update their provider enrollment with the
								Department.)
No
$7.35*
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)
No
$7.08*
90636
Hepatitis A and hepatitis B vaccine (HepA-HepB),
								adult dosage for intramuscular use (Ifunder eighteen (18) years of age,
								"Vaccines For Children" program must be used for this service and documented.
								If under age twenty-one (21) all MaineCare Benefits Manual, Section 94, "Early,
								Periodic, Screening, Diagnosis and Treatment (EPSDT)" requirements for this
								service must be met and documented.
No
$110.64*
90649
Human Papillomavirus (HPV) vaccine types 6, 11, 16,
								18 (quadrivalent), 3 dose schedule, for intramuscular use. (For administration
								to both men and women from nine (9) years until twenty-seven (27) years. I
								funder eighteen (18) years of age, "Vaccines For Children" program must be used
								for this service and documented. If under age twenty-one (21) all MaineCare
								Benefits Manual, Section 94, "Early, Periodic, Screening, Diagnosis and
								Treatment (EPSDT)" requirements for this service must be met and documented.)
No
$120.00*
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.)
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$23.91*
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.
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$41.55*
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.
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$60.20*
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.
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$93.60*
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.
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$118.41*
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.
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$13.17*
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.
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$24.14*
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.
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$40.51*
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.
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$61.05*
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.
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$82.60*
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.)
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$62.06*
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.)
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$61.43*
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)
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$63.32*
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)
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$65.89*
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.)
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$58.37*
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.)
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$58.74*
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
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$58.74*
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)
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$58.74*
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.]
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$6.15*
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.]
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$27.05*
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.]
Apply FP modifier if visit is only to prevent or
								delay pregnancy or to otherwise control family size
$12.29*
A4266
Diaphragm for contraceptive use
FP
$21.48*
A4267
Contraceptive supply, condom, male, each
FP
$0.65*
A4268
Contraceptive supply, condom, female, each
FP
$2.10*
A4269
Contraceptive supply, spermicide (e.g., foam, gel)
								each
FP
$8.60*
J1050
Injection, medroxyprogesterone acetate, 1 mg
FP
$00.24*
J7300
Intrauterine copper contraceptive (Paragard T3880A)
FP
$600.00*
J7301
Levonorgestrel-releasing intrauterine contraceptive
								system, 13.5 mg(Skyla)
FP
$675.73*
J7302
Levonorgestrel-releasing intrauterine contraceptive
								system, 52 mg (Mirena)
FP
$716.00*
J7303
Contraceptive Supply, hormone containing vaginal
								ring, each
FP
$41.78*
J7304
Contraceptive Supply, hormone containing patch, each
FP
$14.78*
J7307
Etongestrel (contraceptive) implant system,
								including implant and supplies (Implanon and Nexplanon)
FP
$588.38*
S4993
Contraceptive pills for birth control
FP
$12.40