Clinical Policy 1E-7, Family Planning Services Revised

Tuesday, December 22, 2020

All temporary Family Planning Services policy flexibilities outlined in COVID-19 Special Bulletins remain in effect as of this publication date. See COVID-19 Special Bulletins for details.

An amended version of Clinical Coverage Policy 1E-7, Family Planning Services with an effective date of Dec. 1, 2020, was posted to the NC Medicaid Clinical Coverage Policy webpage. The following permanent policy updates have been made for “Be Smart” Family Planning Medicaid (MAFDN) and traditional Medicaid beneficiaries.  

  1. Added telehealth service coverage for Established Patient Evaluation and Management Services (CPT codes 99211-99215) and Consultation Services (CPT codes 99241-99245): Telehealth modifier GT must be appended to the appropriate CPT code to indicate that a service has been provided via interactive audio-visual communication. 
  2. Added referral guidelines for interventions in HIV by prophylactic prescription meds through the Ready, Set, PrEP program: The nationwide Ready, Set, PrEP program makes PrEP medications available at no cost to individuals who lack prescription drug coverage through participating drug stores or the Local Health Department.
  3. Added US Preventive Services Task Force (USPSTF) recommendations that align with Family Planning Services.
  4. Added coverage for the following services for MAFDN beneficiaries:
    • 87661: Trichomonas vaginalis, amplified probe technique
    • 82120: Amines, vaginal fluid, qualitative
    • 80053: Comprehensive metabolic panel
    • 87220: Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies)- Added for diagnostic testing 
    • 87563: Mycoplasma Genitalium, amplified probe technique
    • 58661: Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
    • GCN 50767: Moxifloxacin 400 mg tabs
    • J7296: Levonorgestrel-releasing intrauterine contraceptive system, (Kyleena), 19.5 mg
  5. Added the following ICD-10-CM Diagnosis codes to the table of diagnosis codes eligible for MAFDN beneficiaries in Attachment A, for use with the new services added above. 



















  6. Added clarification for Federally Qualified Health Centers (FQHC) and Rural Health Clinic (RHC) providers: 
    • Family Planning services other than those provided to MAFDN beneficiaries are billed as core service. 
    • The core service code T1015 is not allowed with MAFDN services. Evaluation and Management and Preventive Service CPT codes should be billed.
  7. Added MAFDN covered Revenue Codes for use with covered Sterilization procedures for MAFDN beneficiaries.
  8. Added clarification that for MAFDN beneficiaries, the only surgical procedure or hospital services allowed requiring outpatient beneficiary registration is sterilization.
  9. Removed the requirement that a pap test can only be performed at the time of the annual exam and clarified that it can be offered at the time of an annual exam or during an inter-periodic visit. 

Providers are encouraged to review Clinical Coverage Policy 1E-7, Family Planning Services for a detailed overview of other general language and formatting updates to the policy. 


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