C.4 Diabetes Education C.5 Obstetrics and Gynecology C.5.1 Incomplete Antepartum Care C.5.2 Postpartum Care C.

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1 Table of Contents. Section Modifications CMS 500 Form Instructions for Completing the CMS Helpful Tips for Filling out the Paper Claim Form CMS 500 Form Descriptions Telehealth s, Effective February, Appendix A. Adult Residential Care... 5 A. Adult Residential Living Facility- RALF... 5 A.2 Certified Family (CFH)... 5 Appendix B. Agency - Professional... 6 B. Behavior Consultation/Crisis Management (BC/CM)... 6 B.2 Children s Coordination... 6 B.2. Children s DD s Traditional Option... 6 B.2.2 Children s DD s Family-Directed s Option... 6 B.3 Chore s Skilled... 7 B.4 Adult Developmental Disability Agency Codes... 7 B.4. DD Coordinator... 7 B.4.2 Developmental Therapy (DT)... 8 B.4.3 Developmental Therapy (DT) and Occupational Therapy (OT)... 8 B.4.4 Specialized Medical Equipment and Supplies... 8 B.5 Nursing Agency-PDN... 9 B.5. Nursing s... 9 B.6 Personal Care s (PCS)... 9 B.7 Physical Therapy (PT) and Occupational Therapy (OT) s... 9 B.8 Psychotherapy... 9 B.9 Psychotherapy Treatment... 9 B.0 Registered Nurse s Agency DD Waiver B. Residential Habilitation-Agency B.2 Respite Care... 2 B.3 School Based s... 2 B.3. Speech-Language Pathology s B.3.2 Supported Employment s B.3.3 Supports Brokerage - FEA B.3.4 Transportation Appendix C. Allopathic and Osteopathic C. Allergy and Immunology-Clinical and Laboratory Immunology C.. State-Supplied Free Vaccines with or without Evaluation and Management (E/M) Visit C..2 Administration of a Provider Purchased Childhood Vaccine With or Without an Evaluation and Management (E/M) Visit C..3 Administration of a Provider Purchased Adult Vaccine With or Without an Evaluation and Management (E/M) Visit C.2 Anesthesiology C.3 Billing Presumptive Eligibility (PE) Determinations June 27, 207 Page i

2 C.4 Diabetes Education C.5 Obstetrics and Gynecology C.5. Incomplete Antepartum Care C.5.2 Postpartum Care C.6 Oral and Maxillofacial Surgery C.7 Physician Policy Appendix D. Ambulatory Health Care Facility D. Adult Day Care (Health) D.2 Clinic/Center-Federally Qualified Health Center (FQHC) D.3 Clinic/Center-Rural Health Clinics (RHC) D.4 Indian Health Center (IHC) D.5 District Health Department s D.6 Pregnant Women Clinic Appendix E. Behavioral Health and Social Providers Appendix F. Chiropractor Appendix G. Dietary and Nutritional Providers Appendix H. Eye and Vision s Provider Appendix I. Licensed Midwives Appendix J. Nursing and Custodial Care... 3 Appendix K. Nursing s Providers Appendix L. Physician Assistants and Advanced Practice Nursing Providers Appendix M. Respiratory, Developmental, Rehab, and Restorative s Appendix N. Speech, Language, and Hearing Providers N. Audiology s N.2 Speech Therapy Appendix O. Suppliers O. Aged and Disabled (A&D) Waiver O.2 Developmentally Disabled (DD) Waiver O.3 Preventive Health Assistance (PHA) June 27, 207 Page ii

3 . Section Modifications Version Section/ Column Update Publish Date SME 35.0 All Published version 6/27/7 TQD 34. D.2 Clinic/Center Federally Qualified Health Center Added information regarding modifier 59 6/27/7 D Baker E Garibovic (FQHC) D.3 Clinic/Center Rural Health Clinic (RHC) D.4 Indian Health Center (IHC) 34.0 All Published version 6/5/7 TQD 33. D.2 Clinic/Center Federally Qualified Health Center (FQHC) D.3 Clinic/Center Rural Health Clinic (RHC) D.4 Indian Health Center (IHC) Removed modifier information 6/5/7 W Deseron D Baker E Garibovic 33.0 All Published version 5/9/7 TQD CMS 500 Form Descriptions Updates to boxes 7 and 7b to reflect ORP requirements 5/9/7 J Kennedy- King D Baker 32.0 All Published version /7/7 TQD CMS 500 Form Descriptions Updates to boxes 22, 26, 32a, and 32b for clarity /7/7 D Decrevel D Baker E Garibovic 3.0 All Published version 7/28/6 TQD Telehealth s Removed table of codes and added 7/28/6 D Baker reference to fee schedule 30.0 All Published version 5/3/6 TQD 29.2 Appendix Q. Ambulance Removed section 5/3/6 D Baker Transportation s 29. Appendix J. Non-Emergent Removed section 5/3/6 D Baker Transportation Providers 29.0 All Published version 4/25/6 TQD 28. Appendix G. Dietary and Modification to description and coverage 4/25/6 E Garibovic Nutritional Providers for G008, G090, and S9470. Removal of U5 modifier 28.0 All Published version /28/6 TQD 27.2 C.8 Telemedicine Removed section /28/6 D Baker C Brock Telehealth s New section added /28/6 D Baker C Brock 27.0 All Published version /22/6 TQD CMS 500 Form Descriptions Updated fields 0d, 7, and 7b. Removed field 7a. /22/6 M Hurst D Baker C Loveless 26.0 All Published version /5/5 TQD 25. C.. State-Supplied Free Corrected CPT codes /5/5 D Baker Vaccines with or without Evaluation and Management (E/M) Visit 25.0 All Published version 9/0/5 TQD 24. B.4 Adult Developmental Disability Agency Codes Updated fee schedule information; removed therapy modifier for 9/0/5 S Perry C Taylor Developmental Therapy 24.0 All Published version 8/28/5 TQD June 27, 207 Page of 39

4 Version Section/ Column Update Publish Date SME 23. B. Behavior Consultation/Crisis Management B.2 Children's Coordination B.3 Chore s - Skilled B. Residential Habilitation- Agency B.2 Respite Care B.3.2 Supported Employment s Updated for ICD-0 8/28/5 A Coppinger S Perry J Siroky C Burt F Trenkle- MacAlister A Fernandez C Taylor D Baker C.2 Anesthesiology F. Chiropractor 23.0 All Published version 8/4/5 TQD 22.2 O.2 Speech Therapy Removed table and replaced with reference to Fee Schedule 8/4/5 A Coppinger D Baker C Taylor 22. O. Audiology s Updated audiometric testing codes 8/4/5 A Coppinger D Baker C Taylor 22.0 All Published version 7/30/5 TQD CMS 500 Form Changed 7 and 8 to 07 and 08 in 7/30/5 C Taylor Descriptions box All Published version 5/2/5 TQD 20. A.2 Certified Family (CFH) Added table and removed reference to fee schedule 5/2/5 C Taylor D Baker 20.0 All Published version 3/30/5 TQD 9. Appendix K. Nursing and Corrected unit measurement for PCS 3/30/5 C Taylor Custodial Care Family Alternate Care 9.0 All Published version 3/2/5 TQD CMS 500 Form Descriptions Updated note about ECI codes in box 2 for clarity. 3/2/5 C Taylor D Baker 8.0 All Published version 2/26/5 TQD CMS 500 Form Added note about ECI codes in box 2. 2/26/5 C Taylor Descriptions 7.0 All Published version 0/23/ TQD 4 6. Appendix G. Dietary & Nutritional Providers Removed S9452 and added G008, G009 0/23/ 4 K McNeal C Taylor 6.0 All Published version 8/5/4 TQD CMS 500 Form Descriptions Updated boxes 0, 0a, 0b, 0c, and 4 to clarify information 8/5/4 D Decrevel C Taylor D Baker 5.0 All Published version 8//4 TQD 4.7 C.2 Anesthesiology Updated for ICD-0 dates and diagnosis code 8//4 L Neal C Taylor 4.6 B.9.2. Supported Employment s Updated for ICD-0 dates and diagnosis code 8//4 L Neal C Taylor 4.5 B.8 Respite Care Updated for ICD-0 dates and diagnosis code 8//4 L Neal C Taylor 4.4 B.7 Residential Habilitation- Agency Updated for ICD-0 dates and diagnosis code 8//4 L Neal C Taylor 4.3 B.3 Chore s Skilled Updated description, ICD-0 dates and diagnosis code 8//4 L Neal S Perry D Baker 4.2 B.2 Children s Coordination Updated for ICD-0 dates and diagnosis code 8//4 L Neal C Taylor June 27, 207 Page 2 of 39

5 Version Section/ Column Update 4. B. Behavior Consultation/Crisis Management (BC/CM) Updated for ICD-0 dates and diagnosis code Publish Date SME 8//4 L Neal C Taylor 4.0 All Published version 4/8/4 TQD CMS 500 Form Descriptions Updated Field Name and Notes for box 24E to clarify using alpha character 4/8/4 D Decrevel C Taylor 3.0 All Published version 4//4 TQD CMS 500 Form Descriptions Clarified information for entering PA number in Box 23. 4//4 D Decrevel D Baker 2.0 All Published version 3/28/4 TQD.3 Appendix D. Clinic/Center- Rehabilitation, Substance Use Disorder Psychiatric Diagnosis and Evaluation Mental Health Clinic Rehab Mental Health s Removed sections 3/28/4 C Burt C Taylor.2 Appendix B. Psychosocial Rehabilitation s (PSR) Specialized s to Nursing Facility Participants Mental Health Coordination Removed sections 3/28/4 C Burt C Taylor. B..6 Adult DD Agency Codes Removed H0004 3/28/4 C Burt C Taylor.0 All Published version 3/2/4 D Baker C Taylor 0.25 Appendix P. A & D Waiver Updated table information 3/2/4 J Siroky 0.24 Appendix L. Nursing s Updated language, removed codes 3/2/4 S Choules Providers 0.23 Appendix K. Nursing and Custodial Care Updated language, removed codes 3/2/4 S Choules 0.22 D..9 District Health Department s Added supply code J050; removed J055 and J056 Removed procedure code 975; added 98 3/2/4 J Siroky 0.2 D..5 Clinic/Center-IHC Added information to clarify and updated 3/2/4 D Baker table information 0.20 D..4 Clinic/Center-RHC Added information to clarify and updated 3/2/4 D Baker table information 0.9 D..2 Clinic/Center - FQHC Added information to clarify and updated 3/2/4 D Baker table information 0.8 D.. Adult Day Care Updated section title 3/2/4 D Baker (Health) 0.7 B..24 Speech-Language Removed fee schedule information 3/2/4 J Siroky Pathology s 0.6 B..22 School Based s Removed fee schedule information, clarified diagnosis code 3/2/4 F Trenkle- MacAllister 0.5 B..5 PT and OT s Removed fee schedule information 3/2/4 J Siroky 0.4 B..4 PCS Removed fee schedule information 3/2/4 S Choules 0.3 B..3 Nursing s Removed fee schedule information 3/2/4 S Choules 0.2 B..2 Nursing Agency-PDN Removed fee schedule information 3/2/4 S Choules 0. B..0 Medical Equipment Removed fee schedule information 3/2/4 S Choules and Supplies 0.0 B..0 Intensive Behavioral Intervention (IBI) Removed section 3/2/4 F Trenkle- MacAllister 0.9 B..9 DT and OT Removed of all children DD s 3/2/4 F Trenkle- MacAllister June 27, 207 Page 3 of 39

6 Version Section/ Column Update Publish Date SME 0.8 B..8 Developmental Therapy (DT) Removed of all children DD s 3/2/4 F Trenkle- MacAllister 0.7 B..6 Adult Developmental Disability Agency Codes Removed of all children DD s 3/2/4 F Trenkle- MacAllister 0.6 B..4 Children s DD s Family Directed s Removed redesign language, removed all children s services 3/2/4 F Trenkle- MacAllister Option 0.5 B..3 Children s DD s Traditional Option Removed redesign language, removed all children s services 3/2/4 F Trenkle- MacAllister 0.4 A..2 Certified Family Removed fee schedule information 3/2/4 S Choules (CFH) 0.3 A.. Adult Residential Living Removed fee schedule information 3/2/4 S Choules Facility (RALF) CMS 500 Form Updated notes for box 24E 3/2/4 D Decrevel Instructions CMS 500 Form Added requirements for box number 23 3/2/4 D Decrevel Descriptions for PA number 0.0 All Published version /24/4 TQD 9. B..2 Children s Updated PA requirements /24/4 D Baker Coordination 9.0 All Published version 2/20/ TQD Appendix P.3 Preventive Health Assistance Removed tobacco cessation 2/20/ 3 D Baker CMS 500 Form Descriptions Updated descriptions for boxes 4, 9, and 2 to align with new form requirements Added dates of acceptance for old and new forms 2/20/ 3 D Baker Instructions for Completing the CMS 500 Form 2/20/ 3 D Baker 8. 2 CMS 500 Form Replaced screen shot of old form with 2/20/ D Baker new form All Published version /8/3 TQD 7. Appendix K Changed ICF/MR to ICF/ID /8/3 D Baker 7.0 All Published version 0/02/ TQD 2 6. Appendix C.5.2 Postpartum Changed from twin to multiple and 0/02/ C Taylor Care Postpartum Care added modifier All Published version 6//2 TQD 5. Appendix J Non-Emergent Updated section 6//2 D Baker Transportation Providers 5.0 All Published Version 2/28/2 TQD CMS 500 Form Added ME to NDC unit of measure 2/28/2 J Decrevel Descriptions 4.2 Appendix I Licensed Midwives Added Licensed Midwives section 2/28/2 J Siroky 4. B..25 School Based s Added two billing codes for the Infant 2/28/2 L Ertz Toddler Program 4.0 All Published version 0/20/ TQD 3.4 Appendix Q Ambulance Updated heading Transportation s 3.40 Appendix O Speech, Updated information 0/20/ K Mcneal Language, and Hearing Providers 3.39 Appendix H Eye and Vision s Provider Updated information 0/20/ 3.38 Appendix G Dietary and Updated table 0/20/ Nutritional Providers 3.37 Appendix F Chiropractor Updated Diagnosis codes 0/20/ K Mcneal K Mcneal J Siroky June 27, 207 Page 4 of 39

7 Version Section/ Column Update Publish Date 3.36 Appendix E Behavioral Health Updated table 0/20/ and Social Providers 3.35 D..9 District Health Added section 0/20/ Department s 3.34 D..6 Psychiatric Diagnosis Updated table 0/20/ and Evaluation 3.33 D..2 Clinic/Center -Federally Updated modifier and POS 0/20/ Qualified Health Center (FQHC) D..4 Clinic/Center -Rural Health Clinics (RHC) D..5 Indian Health Center (IHC) 3.32 C. Allergy and Immunology- Clinical and Laboratory Immunology Changed to and updated all tables 0/20/ 3.3 B..25 School Based s Removed HCPCS /20/ 3.30 B..23 Residential Removed HCPCS T09 0/20/ Habilitation-Agency 3.29 B..0 Intensive Behavioral Updated table 0/20/ Intervention (IBI) 3.28 B..9 Developmental Therapy Update table 0/20/ (DT) and Occupational Therapy (OT) 3.27 B..8 Developmental Therapy (DT) and Intensive Behavioral Intervention (IBI) Removed HCPCS code /20/ 3.26 B..7 DD Coordinator Updated table 0/20/ 3.25 B..6 Developmental Deleted H0004 0/20/ Disability Agency Codes 3.24 B..4 Children s DD Redesign Added information 0/20/ s Family-Directed s Option 3.23 B..3 Children s DD Redesign Added information 0/20/ s Traditional Option 3.22 B.. Behavior Consultation/Crisis Management (BC/CM) CMS 500 Form Descriptions Updated table 0/20/ Updated information for Box A, 7, 7a, 7b, 9, 24A, 24J (shaded/unshaded), 32 Line, 32a, 32b, 0/20/ 3.20 All Published version 0/20/ 3.9 E.2 FQHC Added modifier and POS 0/20/ 3.8 E.4 RHC Added modifier and POS 0/20/ 3.7 E.6 IHC Added modifier and POS 0/20/ 3.6 Appendix G Chiropractor Removed CPT code 0/20/ 3.5 Field 32b Added If this is included the service facility must be affiliated with the billing facility. 3.4 Field 32a Added If this is included the service facility must be affiliated with the billing facility. 0/20/ 0/20/ SME K Mcneal K Mcneal K Mcneal K Mcneal J Siroky P Grooms P Grooms P Grooms P Grooms L Ertz P Grooms P Grooms L Ertz L Ertz P Grooms K Mcneal TQD K Purney K Purney K Purney A Rameriz J Decrevel J Decrevel June 27, 207 Page 5 of 39

8 Version Section/ Column Update Publish Date 3.3 All Published version 0/20/ 3.2 C..27 Supportive Counseling Removed section 0/20/ 3. C..2 ResHab-Agency Removed T09 0/20/ 3.0 C..8 - IBI Updated descriptions 0/20/ 3.9 C..7 DT and OT Updated descriptions, removed /20/ 3.8 C.5 DD Coordinator Removed G900 Update description for G9002, G9007, H20, H20/HM 3.7 C..4 DD Agency Codes Removed Removed U8 modifier for E399 Removed H0004, HM, Supportive counseling 3.6 C.. Behavior Consultation Crisis Management 0/20/ 0/20/ Updated descriptions 0/20/ 3.5 Appendix G Chiropractor Updated Diagnosis codes 0/20/ 3.4 Field A Updated for clarity, added (Three zero prefix plus seven digit ID number.) 3.3 Field 7, 7a, 7b Updated to read Not required at this time 0/20/ 0/20/ TQD SME P Grooms P Grooms P Grooms P Grooms P Grooms P Grooms P Grooms C Taylor V Schmidt J Gillet 3.2 Field 24 (shaded top) Added A 0/20/ D Decrevel 3. Appendix G Removed diagnosis codes 0/20/ M Wood 3.0 All Published version 8/27/0 TQD 2.38 Appendix Q Updated with information for nonemergent 8/27/0 M Wimmer medical transportation 2.37 All Replaced member with participant 8/27/0 C Stickney 2.36 Appendix P Separated into specialty sections 8/27/0 C Stickney 2.35 All Appendix Alphabetized Appendices for ease of use. 8/27/0 T Kinzler 2.34 All Appendix Alphabetized sections within each 8/27/0 T Kinzler appendix for ease of use Appendix P Added entries for Nicotine Lozenges, 8/27/0 C Brock Nicotine Inhaler, and Nicotine Nasal Spray 2.32 Appendix P Initial Installation fee needs to be called 8/27/0 P Grooms Personal Emergency Response System Initial Installation 2.3 Appendix P Monthly Fee/DD Waiver needs to be called 8/27/0 P Grooms Personal Emergency Response System Monthly Fee 2.30 B..5 Added codes H204, H202, H2032, 8/27/0 P Grooms and with modifier HQ to reflect group therapy Q.2 Added Health 8/27/0 M Meints 2.28 Q. Added Hospice 8/27/0 M Meints 2.27 N. Added multiple codes 8/27/0 M Meints 2.26 M. Added These codes plus other codes for 8/27/0 M Meints state approved therapies and modalities D..0 Updated unit = 5 minutes 8/27/0 M Meints 2.24 D..4 Added Mental Health Clinic 8/27/0 M Meints June 27, 207 Page 6 of 39

9 Version Section/ Column Update Publish Date SME 2.23 D..3 Updated to Rehab Mental Health 8/27/0 M Meints s, added multiple codes 2.22 D..2 Removed 8296A 8/27/0 M Meints 2.2 B..3 Added DDA 8/27/0 M Meints 2.20 B..30 Added PHA 8/27/0 C Taylor 2.9 B..29 Added Supports Brokerage FEA 8/27/0 D Baker 2.8 B..28 Added H20 8/27/0 M Meints 2.7 B..26 Added multiple codes 8/27/0 M Meints 2.6 B..26 Added multiple codes 8/27/0 M Meints 2.5 B..24 Added H20 8/27/0 M Meints 2.4 B..23 Added multiple codes 8/27/0 M Meints 2.3 B..2 Added multiple codes 8/27/0 M Meints 2.2 B..20 Added multiple codes 8/27/0 M Meints 2. B..5 Added multiple codes 8/27/0 M Meints 2.0 B..0 Added multiple codes 8/27/0 M Meints 2.9 CFH-Independent Affiliation Removed 8/27/0 C Taylor Fee 2.8 CFH-Agency Affiliation Fee Removed 8/27/0 C Taylor 2.7 All Removed modifiers U2 U8 8/27/0 C Taylor 2.6 B and H2032 Added HQ modifier 8/27/0 M Meints Added OT Assessment 2.5 B..3 Changed to unit = visit 8/27/0 C Taylor 2.4 B.. Removed 03 School from place of 8/27/0 C Taylor service 2.3 A.. Removed PA number must be billed on 8/27/0 D Baker claim Changed adjustment to replacement 8/27/0 M Wood Field Enter all dates using the month, day, and 8/27/0 D Decrevel year (MM/DD/YY) format. 2.0 All Published version 6/4/0 TQD Updated for clarity 6/4/0 E Charles Updated for clarity 6/4/0 E Charles.2 Field 22 Updated for clarity 6/4/0 E Charles. Field 23 Updated for clarity 6/4/0 E Charles.0 Added Field 24D NDC Unit Price; Required if NDC code is present in 24A; Enter unit price corresponding to NDC code. 6/4/0 E Charles.9 Field 33a Removed note that NPI numbers, sent on paper claims are optional and will not be used for claims processing.8 Removed Interpretation, Bilingual Translation; 8296A; Interpretation for bilingual translation Unit = Hour.7 B..20 DD Removed unit = month initial Coordinator service coordination.6 B..2 Children s Coordination.5 B..2 Children s Coordination Changed Children s Coordinator to Children s Coordination Removed G900 Added the following EPSDT Children s Plan Development, G902, Children s Plan Development, PA is required. Unit = 5 minutes 6/4/0 E Charles 6/4/0 M Meints 6/4/0 M Meints 6/4/0 M Meints 6/4/0 M Meints June 27, 207 Page 7 of 39

10 Version Section/ Column Update.4 B..22 Mental Health Case Management Mental Health Coordination Crisis Updated for clarity.3 D.2. Individual and Group All s were updated for clarity with: Psychotherapy The UA Modifier is required when provided by physician.2 O. Suppliers Added Non-Physician Weight Management and Non-Prescription Tobacco Cessation Publish Date SME 6/4/0 M Meints 6/4/0 M Meints 6/4/0 C Taylor. Multiple Updated diagnosis code V604 to V60.4 6/4/0 C Taylor.0 All Initial document Published version 5/7/0 TQD June 27, 207 Page 8 of 39

11 2. CMS 500 Form June 27, 207 Page 9 of 39

12 3. Instructions for Completing the CMS 500 The updated form (2/202) will be accepted beginning January 5, 204 and the old form (8/2005) will be accepted until April 4, 204. Beginning April 5, 204 only the new form will be accepted. 3.. Helpful Tips for Filling out the Paper Claim Form A maximum of six line items per claim can be accepted. If the number of services performed exceeds six lines, prepare a new claim form and complete all the required elements. Total each claim separately. Enter all dates except the Patient s Birth Date using the 2-digit month, day, and year (MM/DD/YY) format. You can bill with a date span (From and To Dates of ) only if the service was provided every consecutive day within the span. Do not enter any data or documentation on the claim form that is not listed as required below. Consult the Use column to determine if information in any particular field is required. Only fields that are required for billing the Idaho Medicaid program are shown on the following table. There is no need to complete any other fields. Claims will be rejected when required information is not entered into a required field. The following numbered items correspond to the CMS-500 (02/202) claim form CMS 500 Form Descriptions Box No. Field Name Use Notes a Insured s ID Required Enter the Participant s Idaho Medicaid ID number (Three zero prefix plus seven digit ID number.) 2 Patient s Name Required Enter the participant s name exactly as it appears on the Participant s Idaho Medicaid ID card. Enter as last name, first name, middle initial. 3 Patient s Birth Date Required Enter the patient s date of birth. Formatted as MMDDCCYY 3 Sex Required Check the appropriate box indicating the patient s gender. M Male F - Female 5 Patient s Required Enter Patient s Street Address Address 5 City Required Enter the patient s city 5 State Required Enter the patient s 2 character state code. 5 Zip Required Enter patient s 5 or 9 digit zip code. 0 Is patient s condition related to: If condition is related to box 0a, 0b, or 0c then a date is required in box 4. June 27, 207 Page 0 of 39

13 Box No. Field Name Use Notes 0a Employment? Not Required Indicate yes or no if this condition is related to the client s employment; if yes, then a date is required in box 4. 0b Auto Accident? Place (State) Not Required Indicate yes or no if this condition is related to an auto accident. If yes, enter 2 digit state abbreviation of the state where auto accident occurred and a date is required in box 4. 0c Other Accident? Not Required Indicate yes or no if this condition is related to an accident other than an auto accident. If yes, a date is required in box 4. 0d Claim Codes Not Required When applicable, enter the two-digit valid condition claim codes. A maximum of six two-digit alphanumeric codes may be entered. Ensure there is a space between each two-digit code. 4 Date of Current Illness, Injury, or Pregnancy (LMP) 7 Name of Referring, Ordering, or Supervising Provider 7b Referring, Ordering, or Supervising Physician NPI 9 Additional Claim Information Only required if any related cause in box 0 is marked Yes Required for certain specialties Required for certain specialties Not Required Enter Date of Accident or the date the illness or injury first occurred, or the date of the last menstrual period (LMP) for pregnancy and if services being billed are subsequent to initial encounter. Formatted MMDDYY Enter the referring, ordering, or supervising physician s name formatted: Last Name, First Name, Middle Initial Enter a qualifier of DN for referring provider, DK for ordering provider, or DQ for supervising provider. Enter the referring, ordering, or supervising physician s 0-digit NPI. Use as a remarks field to indicate information helpful for claims processing, e.g. injury/accident how, where, and when injury/accident happened. June 27, 207 Page of 39

14 Box No. Field Name Use Notes 2 (A-L) Diagnosis or Nature of Illness or Injury At least one Required Enter the appropriate ICD-9-CM/ICD-0- CM codes (up to 2). Enter the primary diagnosis in 2(A). If applicable, B, C, and other diagnosis in 2 (A-L). Always enter the entire diagnosis code including the decimal point. Enter a 9 for ICD-9-CM or a zero for ICD- 0-CM codes in the ICD Ind. field. 22 Resubmission Code 22 Original REF. NO. 23 Prior Authorization Number 24A (unshaded) 24A (shaded top) 24B (unshaded) 24B (shaded top) 24C (unshaded) Date of - From/To NDC code Place of NDC Unit of measure EMG Required if claim is a resubmission Required if claim is a resubmission Required if services need a PA Required Required if appropriate Required Required if NDC code is present in 24A Required, if applicable Note: External Cause of Injury/Morbidity codes are not billable as the primary diagnosis on CMS 500 claims. Enter 7 if claim is a replacement claim. Enter 8 if this claim voids a previously submitted claim. Only enter a value in this field if sending a replacement or void to a previously submitted claim, otherwise leave blank. Enter the claim ID number of the original claim to be voided or replaced. Only enter a value in this field if sending a replacement or void to a previously submitted claim, otherwise leave blank. Enter the PA number exactly as it appears on the Notice of Decision. Enter the from and to date(s) the service was provided, using the following format: MMDDYY Enter N4 followed by the digit NDC code Enter the appropriate 2 digit numeric code Enter appropriate 2 digit NDC unit of measure Valid values: F2 - International Unit GR Gram ME - Milligram ML - Milliliter UN - Unit If the services performed are related to an emergency, mark this field with an X. June 27, 207 Page 2 of 39

15 Box No. Field Name Use Notes 24C-D (shaded top) 24D (unshaded) 24D (unshaded) 24D (shaded top modifier section) 24E (unshaded) 24F (unshaded) 24G (unshaded) 24H (unshaded) 24I (shaded) 24J (shaded top) 24J (unshaded) NDC number of Units Procedures, s, or Supplies Required if NDC code is present in 24A Required Enter the actual metric decimal quantity (units) administered to the patient. If reporting a fraction of a unit, use the decimal point. Nine numbers may precede the decimal point and three numbers may follow the decimal. Enter the appropriate five-character HCPCS procedure code to identify the service provided. Modifier Desired If applicable, add the appropriate HCPCS two digit modifier(s). Enter as many as four. Otherwise, leave this section blank. NCD Unit Price Diagnosis Pointer Required if NDC code is present in 24A Required if diagnosis code in block 2 is present Enter unit price corresponding to NDC code. Use A-L for the corresponding diagnosis code entered in field 2. Charges Required Enter the usual and customary fee for each line item or service. Do not include tax. Days or Units Required Enter the quantity or number of units of the service provided. Maximum value of If there is a zero leading a value you need to remove it (IE. 0 will be ). EPSDT Family Required if Not required unless applicable. If the Plan applicable services performed constitute an EPSDT program screen, refer to the instructions for EPSDT claims in the provider handbook. ID. Qualifier for service line rendering provider Rendering Provider ID Number Rendering Provider NPI Required Required if rendering provider is billing with Idaho Medicaid ID. Required if rendering provider is different from billing provider Enter line rendering provider id only if provider rendering the service is different than billing provider. Enter qualifier D followed by Idaho Medicaid provider number in 24J, only if Rendering Provider is not registered with an NPI. Enter line rendering provider id only if provider rendering the service is different than billing provider. Enter Rendering Provider Medicaid ID only if Rendering provider is not registered with an NPI. Enter line rendering provider NPI only if provider rendering the service is different than billing provider. June 27, 207 Page 3 of 39

16 Box No. Field Name Use Notes 25 Federal Tax ID Number Required Enter the Federal Tax ID. Must be 9 numeric characters. 26 Patient Required Enter patient account number. Account Number 28 Total Charge Required Enter total of all service line charges 32 Line Facility Name 32 Line 2 Facility Address line 32 Line 3 Facility Address line 2 32 Line 3 or 4 32a 32b Facility City, State and Zip Code Facility Location ID (NPI) Facility Location ID (blank) 33 Line Billing Provider Name Required if Facility Location is present in 32a Required if Facility Location ID is present in 32a Not Required Required if Facility Location is present in 32a Required, if applicable Required, if applicable Required Enter name of service facility only if Location is different than Billing Provider name in box 33, otherwise leave box 32 blank. If this is included the service facility must be affiliated with the billing facility. Enter Street Address of Facility, only if Location address is different than Billing Provider address in box 33, otherwise leave box 32 blank. Enter additional service facility address line if needed and service location if different than billing provider address in box 33, otherwise leave box 32 blank. Enter Facility city, state, and zip code, only if Location address is different than Billing Provider address in box 33, otherwise leave box 32 blank. If you bill with an NPI, enter the ten-digit NPI followed by a dash and the three-digit service location identifier only if the services were rendered at a location other than that of the billing provider in box 33. Do not enter any other value in box 32a. For example, If this is included the service facility must be a part of your billing facility. If you bill with an Idaho proprietary number (not an NPI) enter the eight-digit provider ID followed by a dash and the three-digit service location identifier only if rendered at a location other than that of the billing provider in box 33. Do not enter any other value in box 32b. For example, M or A If this is included the service facility must be a part of your billing facility. Enter billing provider name June 27, 207 Page 4 of 39

17 Box No. Field Name Use Notes 33 Line 2 Billing Provider Required Enter street address of billing provider Address line 33 Line 3 Billing Provider Address line 2 Not Required Enter additional billing provider address line, if needed 33 Line 3 or 4 Billing Provider city, state, and zip code Required Enter billing provider city, state, and zip code 33a NPI Number Required, if billing with an NPI 33b Billing Provider Medicaid ID Required if not billing with NPI in 33a Enter the 0-digit NPI number of the billing provider. Enter the qualifier D followed by the provider s 8-digit proprietary Idaho Medicaid provider number with no spaces in between. 4. Telehealth s, Effective February, 206 All reimbursable telehealth services must be provided and billed in accordance with appropriate licensure standards, Idaho Medicaid Telehealth Policy, Information Release MA5-, and applicable handbooks. Codes covered by telemedicine must always be billed with the GT modifier. For telehealth codes, please see the the Telehealth Fee Schedule on the DHW website. Appendix A. Adult Residential Care A. Adult Residential Living Facility- RALF Refer to the current Fee Schedules for Personal Care and Community Based s Aged & Disabled Waiver s. A.2 Certified Family (CFH) HCPCS S540 T09 S500 H20 Description Certified Family Daily One to two participants Foster Care Adult; per diem unit = day Personal Care per 5 minutes Adult Foster Care Crisis intervention per 5 minutes Place of 2 33 Custodial Care Facility 99 Other June 27, 207 Page 5 of 39

18 Appendix B. Agency - Professional B. Behavior Consultation/Crisis Management (BC/CM) HCPCS Modifier Description Diagnosis H209 Therapeutic Behavioral s Unit = 5 minutes H209 HM Therapeutic Behavioral s Limited to 96 units per calendar month. Unit = 5 minutes H20 Community Crisis supports ( unit = 5 minutes) Based on dates of service, enter the ICD-9- CM code V60.4 or the ICD-0-CM code Z74.2 for the primary diagnosis. For more information on which ICD version to use, refer to ICD-9 and ICD- 0 Diagnosis Billing Requirements. Place of Office 2 99 Other (Community) B.2 Children s Coordination HCPCS Modifier Description Diagnosis G9002 Coordinated Care Fee, Maintenance Rate (Ongoing Children s Coordination) Unit = 5 minutes, PA is required. G9002 HM Coordination Paraprofessional, PA is required. G9003 G902 Coordinated Care Fee, Risk Adjusted High, Initial (Emergency service coordination). PA is required by Medicaid. Unit = 5 minutes Children s Plan Development. Unit = 5 minutes H20 Children s Crisis Assistance ( unit = 5 min) H20 HM Children s Crisis Assistance Paraprofessional ( unit = 5 min) B.2. Children s DD s Traditional Option Refer to the current Fee Schedules for Children s DD s. B.2.2 Based on dates of service, use the ICD- 9-CM diagnosis code V60.4 or ICD-0-CM code Z74.2 as the primary diagnosis code for personal care case management. For more information on which ICD version to use, refer to ICD-9 and ICD-0 Diagnosis Billing Requirements. Children s DD s Family-Directed s Option Refer to the current Fee Schedules for Children s DD s. June 27, 207 Page 6 of 39

19 B.3 Chore s Skilled HCPCS Description Diagnosis S52 Chore s (Skilled) Based on dates of service, enter the ICD-9-CM code V60.4 or the ICD-0- CM code Z74.2 for the primary diagnosis. Place of 2 Hom e For more information on which ICD version to use, refer to ICD-9 and ICD- 0 Diagnosis Billing Requirements. B.4 Adult Developmental Disability Agency Codes CPT/ HCPCS Modifier Description T2025 Residential Care (NOS) Waiver; per diem rate ( unit = day) /Community Individual and/or Group Developmental Therapy for Adults ( unit = 5 minutes) E399 Specialized Medical Equipment (75% of vendor s retail price) H2000 Developmental Therapy Evaluation ( unit = 5 minutes) H205 Individual Supported Living ( unit = 5 minutes) H205 HQ Group Supported Living ( unit = 5 minutes) H209 U Behavioral Consultation by Psychiatrist ( unit = 5 minutes) H209 HM Intensive Behavioral Intervention Paraprofessional ( unit = 5 minutes) H2032 Center Based Individual and/or Group Developmental Therapy for Adults ( unit = 5 minutes) S500 Adult Day Care ( unit = 5 minutes) T028 Social History/Evaluation ( unit = 5 minutes) B.4. DD Coordinator HCPCS Modifier Description G9002 Adult DD Coordination Unit= 5 min G9002 HM Adult DD Coordination Paraprofessional ( unit = 5 min) G9007 Adult DD Plan Development Unit = 5 minutes H20 Adult DD Crisis Assistance ( unit = 5 min) H20 HM Adult DD Crisis Assistance Paraprofessional ( unit = 5 min) June 27, 207 Page 7 of 39

20 B.4.2 Developmental Therapy (DT) CPT/ Description HCPCS H20 Intervention for participant in crisis situations. (See IDAPA , Subsection 63.3 for specific requirements). is limited to a maximum of 20 hours per crisis, for 5 consecutive days. may not exceed 20 hours per crisis. Unit = 5 Minutes. B.4.3 Developmental Therapy (DT) and Occupational Therapy (OT) CPT/ HCPCS Modifie r Description H2000 Developmental Therapy Evaluation: Specify exact time. Unit = 5 Minutes. H2032 Center Based Individual Developmental Therapy for Adults Individual activity therapy. Unit = 5 Minutes. (PA required for adults in the DD care management process) H2032 HQ Center Based Group Developmental Therapy for Adults Group activity therapy. Unit = 5 Minutes. (PA required for adults in the DD care management process) OT evaluation. Specify exact time. Unit = evaluation OT re-evaluation Individual Occupational Therapy Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, individual. Specify exact time. Unit = 5 Minutes Individual /community Developmental Therapy for Adults Unit = 5 Minutes. (PA required for adults in the DD care management process) HQ Group /community Developmental Therapy for Adults, two or more individuals. Unit = 5 Minutes. (PA required for adults in the DD care management process) B.4.4 Specialized Medical Equipment and Supplies HCPCS Description Requires PA E399 DME, miscellaneous. Item = Unit. Yes Note: All items require invoice or MSRP. June 27, 207 Page 8 of 39

21 B.5 Nursing Agency-PDN Refer to the current Fee Schedules for Personal Care and Community Based s Aged & Disabled Waiver s. Place of : (2) ; (99) other unlisted facility B.5. Nursing s Refer to the current Fee Schedules for Personal Care and Community Based s Aged & Disabled Waiver s. B.6 Personal Care s (PCS) Refer to the current Fee Schedules for Personal Care and Community Based s Aged & Disabled Waiver s. B.7 Physical Therapy (PT) and Occupational Therapy (OT) s Refer to the current Fee Schedules for Independent Therapy for a list of covered services. B.8 Psychotherapy CPT Description Unlisted psychiatric service. This code was previously, Individual Psychiatric Therapy. Note: This is an interim code to be used by schools to be able to bill for psychotherapy services. This code should be used instead of 90804, 90806, and Professional only. Unit = 5 Minutes Group psychotherapy; Two or more students. Professional only. Specify exact time. Unit = 5 Minutes Family psychotherapy (conjoint psychotherapy) (with patient present). Professional only. Specify exact time. Unit = 5 Minutes Family psychotherapy without patient present. Must be face-to-face with at least one family participant present. The participant must be the focus of services. Professional only. Goals of treatment must be specified on the participants individualized treatment plan. Unit = 5 Minutes. B.9 Psychotherapy Treatment CPT/ HCPCS H0004 Modifie r Description Behavioral health counseling and therapy, individual. Specify exact time. Unit = 5 Minutes Psychotherapy; two or more individuals. Specify exact time. Unit = 5 Minutes. June 27, 207 Page 9 of 39

22 CPT/ HCPCS Modifie r Description Family psychotherapy; (with patient present). Specify exact time. Unit = 5 Minutes. B.0 Registered Nurse s Agency DD Waiver HCPCS T00 T00 T000 T000 T000 T00 Description Nursing Assessment/Evaluation Occurrence = assessment/evaluation Nursing Assessment /Evaluation Occurrence = assessment/evaluation Private Duty/Independent Nursing s Licensed Unit = 5 minutes Private Duty/Independent Nursing s Licensed Unit = 5 minutes Private Duty Nursing/Independent Nursing s Licensed Minimum age is 2. Unit = 5 minutes Nursing Assessment/Evaluation Occurrence = assessment/evaluation. Place of 2 99 Other (unlisted facility) B. Residential Habilitation-Agency HCPCS Modifier Description Diagnosis H20 H205 Community Crisis Supports ( unit = 5 min) Comprehensive Community Support s; per 5 minutes (24-hour/day unavailable under hourly services) for participants who live in their own home or apartment or live with a non-paid caregiver. This code requires PA. Unit = 5 minutes H205 HQ Comprehensive Community Support s; per 5 minutes Supported living for two or three participants who live in their own home or apartment or live with a non-paid caregiver. This code requires PA. Unit = 5 minutes 24 hour/day unavailable under hourly serviced. Based on dates of service, enter the ICD-9-CM code V60.4 or ICD-0-CM code Z74.2 for the primary diagnosis. For more information on which ICD version to use, refer to ICD-9 and ICD-0 Diagnosis Billing Requirements. Place of 2 (CFH, participant s own home, or home of unpaid family) 99 Other (Community) This code should only be used when the participant receives hourly supported living to access the June 27, 207 Page 20 of 39

23 HCPCS Modifier Description Diagnosis H2022 Community Based s, per diem 24 hours per day support and supervision. Provided through a blend of : and group staffing. H206 Comprehensive Community Support s, per diem 24 hours per day support and supervision. Typically requires : staffing but requests for blend of : and group staffing will be reviewed on a case-by-case basis. S500 Day Care s Adult; per 5 minutes S540 Certified Family Foster Care Adult; per diem T2025 Agency - Certified Family Affiliation Fee DD Waiver Agency - Certified Family Affiliation Fee PA number must be billed on claim for payment consideration Certified Family (CFH) - Agency Affiliation Fee Place of community. All other RES/HAB should be coded as. B.2 Respite Care HCPCS Description Diagnosis Place of T005 Respite Care s, up to 5 minutes Unit = 5 minutes. Maximum of six hours per day or 24 units. Based on dates of service, enter the ICD- 9-CM code V60.4 or ICD-0-CM code Z74.2 for the primary diagnosis. 2 (CFH, participant s own home, or home of unpaid family) S925 Respite Care, In the, per diem Unit = day B.3 School Based s For more information on which ICD version to use, refer to ICD-9 and ICD-0 Diagnosis Billing Requirements. Refer to the current Fee Schedules for School-Based s. 99 Other (Community) This code should only be used when the participant receives hourly supported living to access the community. All other RES/HAB should be coded as,. Diagnosis Codes: The diagnosis code must be specific to the student s health condition that qualifies them to receive services and allows the school to receive Medicaid reimbursement. June 27, 207 Page 2 of 39

24 B.3. Speech-Language Pathology s Refer to the current Fee Schedules for Independent Therapy for a list of covered services. B.3.2 Supported Employment s HCPC S H20 H2023 Description Community Crisis Supports ( unit = 5 minutes) Supported Employment, per 5 minutes The maximum allowable units per week are 60. Unit = 5 minutes Diagnosis Based on dates of service, enter the ICD-9-CM code V60.4 or the ICD-0-CM code Z74.2 for the primary diagnosis. For more information on which ICD version to use, refer to ICD-9 and ICD-0 Diagnosis Billing Requirements. Place of 99 Other (Community) B.3.3 Supports Brokerage FEA HCPCS Description Notes T2040 T2025 Financial management selfdirected waiver per 5 minutes Waiver services not otherwise specified Monthly amount based on UCR fee schedule Pay as billed B.3.4 Transportation HCPC T200 S A0080 Description Non emergency transportation, patient attendant/escort. Specify exact time. Unit = 5 Minutes. Non-emergency Non-Medical transportation, per mile, vehicle provided by volunteer (individual or organization), with no vested interest. Specify number of miles from pick-up to delivery. Prior Authorization for waiver service required. unit = mile June 27, 207 Page 22 of 39

25 Appendix C. Allopathic and Osteopathic C. Allergy and Immunology-Clinical and Laboratory Immunology C.. State-Supplied Free Vaccines with or without Evaluation and Management (E/M) Visit CPT Modifier State-Supplied Free Vaccines with or without and Evaluation and Management (E/M) Visit to SL If there is a significant, separately identifiable service, performed, at the time of the vaccine administration, an appropriate E/M code may also be billed with modifier 25. Billed Amoun t $0.00 C..2 Administration of a Provider Purchased Childhood Vaccine With or Without an Evaluation and Management (E/M) Visit CPT Modifier Administration of a Provider Purchased Childhood Vaccine With or Without an Evaluation and Management (E/M) Visit to If there is a significant, separately identifiable service, performed, at the time of the vaccine administration, an appropriate E/M code may also be billed with modifier 25. C..3 Administration of a Provider Purchased Adult Vaccine With or Without an Evaluation and Management (E/M) Visit CPT Modifier Administration of a Provider Purchased Adult Vaccine With or Without an Evaluation and Management (E/M) Visit 9047 to If there is a significant, separately identifiable service, performed, at the time of the vaccine administration, an appropriate E/M code may also be billed with modifier 25 June 27, 207 Page 23 of 39

26 C.2 Anesthesiology CPT Modifier Diagnosis To bill for the epidural injections use the appropriate CPT procedure codes A repeat anesthesia procedure on the same day which is billed with the CPT modifier 76 or 77 will be paid at $0.00. AA Anesthesia services personally performed by an anesthesiologist. The AA modifier is used for all basic procedures AD Medical supervision by a physician, more than four concurrent anesthesia procedures. P Normal healthy patient. P2 Patient with mild systemic disease P3 Patient with severe systemic disease P4 Patient with severe systemic disease that is a constant threat to life P5 Moribund patient who is not expected to survive without the operation. QS Monitored anesthesia care service (can be billed by CRNA or a physician). Modifier QS (Monitored Anesthesia Care) is for informational purposes. Please report actual monitoring time on the claim form. This modifier must be billed with another modifier to show that the service was personally performed or medically directed. QX CRNA service, with medical direction by a physician. QY Medical direction of one CRNA by an anesthesiologist. QZ CRNA service, without medical direction by a physician. Based on dates of service, the ICD-9 code V25.2 or the ICD-0 code Z30.2 must be used for sterilizations. For more information on which ICD version to use, refer to ICD-9 and ICD-0 Diagnosis Billing Requirements. Unit of Enter total units ( unit = minute) for time C.3 Billing Presumptive Eligibility (PE) Determinations Billing Presumptive Eligibility (PE) Determinations HCPCS T023 to bill for PE determination. C.4 Diabetes Education Group Counseling Individual Counseling G009 G008 HCPCS June 27, 207 Page 24 of 39

27 C.5 Obstetrics and Gynecology C.5. Incomplete Antepartum Care Billing for Incomplete Antepartum Care CPT When billing for four to six prenatal visits When billing for seven or more prenatal visits with or without an initial visit C.5.2 Postpartum Care CPT Modifier Billing for Multiple Deliveries For additional babies: 59409, 5954, 5962, or and 59 C.6 Oral and Maxillofacial Surgery Oral and Maxillofacial Surgery HCPCS Do not use CPT procedure code 4899, as this is an unspecified code and will cause delay in payment for services. C.7 Physician Policy Locum Tenens and Reciprocal Billing Modifier Q5 - furnished by a substitute physician under a reciprocal billing arrangement. Q6 - furnished by a locum tenens physician Appendix D. Ambulatory Health Care Facility D. Adult Day Care (Health) HCPCS Description Modifier Place of S500 Day Care s, Adult Unit = 5 minutes U2 modifier is no longer required when billing this service code Other (Community) D.2 Clinic/Center-Federally Qualified Health Center (FQHC) Bill the encounter using procedure code T05 with the appropriate rate on the first detail line. Providers are required to list all the CPT/HCPCS services provided during the encounter priced at zero dollars on subsequent lines. CPT codes included with the T05 encounter code must accurately indicate the service(s) provided during the encounter and conform to National Correct Coding Initiative (NCCI) standards. Claims submitted without the corresponding CPT/HCPCS codes will be denied. June 27, 207 Page 25 of 39

28 HCPCS Diagnosis Description Place of Clinic/ Center - FQHC T05 Use appropriate diagnosis code for services rendered. (i.e., Well Child Exam, Family Planning) All FQHC clinics must use procedure code T05 for medical services. Modifier 59 should be used for same-day repeat service. 50 D.3 Clinic/Center-Rural Health Clinics (RHC) Bill the encounter using procedure code T05 with the appropriate rate on the first detail line. Providers are required to list all the CPT/HCPCS services provided during the encounter priced at zero dollars on subsequent lines. CPT codes included with the T05 encounter code must accurately indicate the service(s) provided during the encounter and conform to National Correct Coding Initiative (NCCI) standards. Claims submitted without the corresponding CPT/HCPCS codes will be denied. HCPCS Diagnosis Description Place of Clinic/ Center - Rural Health Clinics T05 Use appropriate diagnosis code for services rendered. (i.e., Well Child Exam, Family Planning) All rural health clinics must use procedure code T05 for medical services. Modifier 59 should be used for same-day repeat service. 72 D.4 Indian Health Center (IHC) Bill the encounter using procedure code T05 with the appropriate rate on the first detail line. Providers are required to list all the CPT/HCPCS services provided during the encounter priced at zero dollars on subsequent lines. CPT codes included with the T05 encounter code must accurately indicate the service(s) provided during the encounter and conform to National Correct Coding Initiative (NCCI) standards. Claims submitted without the corresponding CPT/HCPCS codes will be denied. HCPCS Diagnosis Description Place of Clinic/ Center - Indian Health Clinics T05 Use appropriate diagnosis code for services rendered. (i.e., Well Child Exam, Family Planning) All rural health clinics must use procedure code T05 for medical services. Modifier 59 should be used for same-day repeat service. 5 June 27, 207 Page 26 of 39

29 D.5 District Health Department s Procedure Codes All claims for services or supplies that are provided as part of a family planning visit must include the FP (Family Planning) modifier with one or more of the following CPT or HCPCS codes. CPT Code Description 9920 Office or other outpatient visit, new patient (Family planning, brief exam) Office or other outpatient visit, new patient (Family planning, interim visit) Office or other outpatient visit, new patient (Family planning, yearly visit) 992 Office or other outpatient visit, established patient (Family planning, brief exam) 9923 Office or other outpatient visit, established patient (Family planning, interim visit) 9924 Office or other outpatient visit, established patient (Family planning, yearly visit) Supply Code Description S4993 Contraceptive pills for birth control (monthly supply). J050 Injection, medrowyprogesterone acetate, mg J7300 Intrauterine copper contraceptive (Paragard T380A). J7302 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg (Mirena IUD). J7303 Hormone containing vaginal ring (NuvaRing). J7304 Contraceptive supply, hormone containing patch, each (Ortho-Evra patch). J7306 Levonorgestrel (contraceptive) implant system, including implants and supplies. J7307 Etonogestrel (contraceptive) implant system, including implant and supplies (Implanon). A4266 Diaphragm for contraceptive use. See Section Reporting National Drug Code (NDC) for Drugs Billed with HCPCS Codes in the Allopathic and Osteopathic Physicians section of the Provider Handbook. Procedur e Code Description (Only allowable to physicians, physician assistants, and nurse practitioners.) Insertion of IUD 5830 Removal of IUD 976 Removal, implantable contraceptive capsules 98 Insertion, non-biodegradable drug delivery implant D.6 Pregnant Women Clinic CPT/HCPC S Description 8025 Urine pregnancy test, by visual color comparison methods G900 Coordinated care fee, initial rate June 27, 207 Page 27 of 39