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Minnesota Family Planning Program (MFPP) Procedure Codes

Revised: 05-01-2017

00840

Anesth, surg low abdmn

00851

Anesth, tubal lig/transect

00920

Anesth, genitalia surgery

00921

Anesth, vasectomy

00950

Anesth, vaginal endoscopy

00952

Anesth, uterine endoscopy

11976

Removal of contracep cap

11981

Insert drug implant device

11982

Remove drug implant device

11983

Remove/reinsert implant device

49320

Diag laparo separate proc

49321

Laparoscopy, biopsy

49329

Lap proc, abdm/per/omentum

52010

Cystoscopy & duct catheter

54500

Biopsy of testis, needle

54505

Biopsy of testis, incis

54865

Exploration of epididymis

54830

Excision epididymis lesion

54900

Fuse sperm ducts, unilateral

54901

Fuse sperm ducts, bilateral

55200

Vas cannul w/wo incis

55250

Vas, uni/bilat postop semen exam

55300

Prep for sperm duct x-ray

55450

Ligation sperm duct

55520

Excis sperm cord lesion

55530

Revise sperm cord veins

55535

Revise sperm cord veins abd

55540

Excis hernia & sperm veins

55600

Vesiculotomy

55605

Vesiculotomy; complicated

55680

Excis Mullerian duct cyst

55870

Electroejaculation

57150

Vag irrigate/med app tx

57160

Insert pessary sup device

57170

Fit diaphragm/cap

57410

Pelvic exam under anesth

57505

Endocervical curettage

57700

Revision of cervix

57720

plastic repair cervix

57800

Dilation of cervical canal

58100

Biopsy uterus lining

58120

Dilation & curettage

58140

Myomectomy abd approach

58145

Myomectomy vag approach

58300

Insertion IUD

58301

Remove IUD

58340

Inject for ut/tube x-ray

58345

Reopen fallopian tube

58350

Chromotubation oviduct

58400

Uterine suspension

58540

Hyseroplasty, (Strassman)

58555

Hysteroscopy, diagnostic

58558

Hysteroscopy, biopsy

58559

Hysteroscopy, lysis

58560

Hysteroscopy resect septum

58561

Hysteroscopy remove myoma

58565

Hysteroscopy bi tube cannul

58600

Ligate/transect tubal, ab/vag

58605

Lig/tran tubal uni/bi postpart same stay

58611

Ligation oviduct(s)

58615

Fal tube occlusion w device

58660

Laparoscopy lysis

58670

Lap w fulg ovid w/wo transect

58671

Lap w occlus ovid by device

58672

Laparoscopy fimbrioplasty

58673

Laparoscopy salpingostomy

58700

Salpingectomy

58740

Lysis of adhesions

58752

Revise ovarian tube(s)

58760

Fimbrioplasty

58770

Salpingostomy

58825

Transposition, ovary(s)

58900

Biopsy of ovary

58920

Wedge resec/bisect ovary uni/bi

74000

Rad exam, abd 1 anteropost

74740

Hysterosalpingography

74742

X-ray fallopian tube

76856

Echography pelvic complete

76857

Echography pelvic

76870

Echography scrotum

76872

Ultrasound transrectal

76948

Echo guide ova aspiration

77080

DXA axial

77081

DXA appendicular

80061

Lipid panel

80076

Hepatic function panel

81000

Urinalysis with microscopy

81001

Urinalysis auto w/scope

81002

Urinalysis nonauto no scope

81003

Urinalysis auto w/o scope

81004

Urinalysis Single Compon

81005

Urinalysis qual/semiquan

81006

Urine volume measurement

81007

Urinalysis for bacteriuria

81010

Urinalysis Con & Dilu Test

81011

Urinalysis H2ODep Test

81012

Urine H2O Dp Tst w Vso Rsp

81015

microscopic urine exam

81025

Urine Pregnancy Test

82270

Test feces for blood

82465

Assay serum cholesterol

82670

Estradiol

82746

Folic acid; serum

82947

Assay quantitative glucose

82951

Glucose tolerance test GTT

83000

Gn pituitary FSH bioassay

83001

Gonadotropin FSH

83002

Gonadotropin LH

83020

Hemoglobin assay

83986

pH body fluid assay

84146

Prolactin

84443

TSH

84702

hCG quantitative

84703

hCG qualitative

84830

Ovulation tests

85002

Bleeding time

85004

Automated diff wbc count

85007

Differential WBC count

85008

Nondifferential WBC count

85013

Spun microhematocrit

85014

Hematocrit

85018

Hemoglobin

85025

Auto hemogram diff WBC

85027

Auto CBC

85032

Manual cell count each

85049

Automated count platelet

85610

Prothrombin time

85651

Sedimentation rate non-auto

85652

Rbc sed rate, auto

85730

PTT

86592

Blood serology qualitative

86593

Blood serology quantitative

86631

Antibody; Chlamydia

86632

Antibody; Chlamydia, IgM

86687

Antibody; HTLV-I

86688

Antibody; HTLV-II

86689

HTLV/HIV confirm test

86695

Herpes simplex type 1

86696

Herpes simplex type 2

86701

HIV-1

86702

HIV-2

86703

HIV-1/HIV-2 single assay

86706

Hep B surface ab test

86780

Treponema pallidum, confirm

86803

Hep C antibody

87070

Bac cult not urine,bld/stool

87075

Culture bacteria specimen

87081

Culture bacteria screen

87086

Urine cult quan count

87088

Bac cult w isol &ID isolates

87109

Mycoplasma cult

87110

Culture chlamydia

87140

culture typing fluorescent

87181

Antibiotic sensitivity

87184

Antibiotic sensitivity

87205

Smear stain & interpret

87206

Smear stain & interpret

87207

Smear stain & interpret

87210

Smear stain & interpret

87252

Virus inoculate for test

87254

Virus inoculate shell vial

87255

Genet virus isolate, hsv

87270

Chylmd trach ag, dfa

87273

Herpes simplex 2, ag, if

87274

Herpes simplex ag, dfa

87285

Influenza b, ag, if

87320

Chylmd trach ag, eia

87340

Hep b surface ag, eia

87350

Infect antigen detect

87389

HIV-1 antigen(s), HIV-1& HIV-2 antibodies

87390

Infect antigen det HIV-1

87391

Hiv-2 ag, eia

87449

Ag detect nos, eia, mult

87490

Chylmd trach dna dir probe

87491

Chylmd trach dna amp probe

87492

Chylmd trach, dna, quant

87528

Hsv, dna, dir probe

87530

Hsv, dna, quant

87531

Hhv-6, dna, dir probe

87532

Hhv-6, dna, amp probe

87533

Hhv-6, dna, quant

87534

Hiv-1, dna, dir probe

87535

Hiv-1, dna, amp probe

87536

Hiv-1, dna, quant

87537

Hiv-2, dna, dir probe

87538

Hiv-2, dna, amp probe

87539

Hiv-2, dna, quant

87590

N.gonorrhoeae dna dir prob

87591

N.gonorrhoeae dna amp prob

87592

N.gonorrhoeae dna quant

87623

Detect test for HPV (low risk types)

87624

Detect test for HPV (high risk types)

87625

Detect test for HPV (HPV types 16 & 18 only

87797

Detect agnt nos dna dir

87798

Detect agnt nos dna amp

87799

Detect agnt nos dna quant

87800

Detect agnt mult dna direc

87806

HIV antigen w HIV antibodies

87810

Chylmd trach assay w/optic

88141

Cytpath crv/vag interp

88142

Cytpath crv/vag t/layer

88143

Cytpath c/vag t/layer redo

88144

Cytpth c/vag t/layer auto

88145

Cytpth c/vag t/layer selct

88147

Cytpath c/vag automated

88148

Cytpath c/vag auto rescrn

88150

Cytopath, pap smear

88151

Cytopath interpret

88152

Cytopath cerv/vag auto

88153

Cytpath c/vag redo

88154

Cytpath c/vag select

88155

Cytopath pap smear

88156

TBS smear Bethesda System

88157

TBS smear Bethesda System

88158

Cytopath cerv/vag tbs auto

88160

Cytopathology

88161

Cytopathology

88162

Extensive cytopathology

88164

Cytpath tbs c/vag manual

88165

Cytpath tbs c/vag redo

88166

Cytpth tbs c/vag auto redo

88167

Cytpath tbs c/vag select

88174

Cytopath c/v auto in fluid

88175

Cytpth c/v auto fluid redo

88300

Level 1 surg path gross only

88302

Lev 2 surg path gross & micro appendix incidental fall tube sterilization

89300

Semen analy; include Huhner test

89321

Semen analysis

93975

Vascular study

93976

Dup scn flw art in&ven out

96372

Ther/proph/diag inj, sc/im

99078

Grp health ed

99201

Office/outpt visit–new pt

99202

Office/outpt visit–new pt

99203

Office/outpt visit–new pt

99204

Office/outpt visit–new pt

99205

Office/outpt visit–new pt

99211

Office/outpt visit–est pt

99212

Office/outpt visit–est pt

99213

Office/outpt visit–est pt

99214

Office/outpt visit–est pt

99215

Office/outpt visit–est pt

99241

Office consultation

99242

Office consultation

99243

Office consultation

99244

Office consultation

99245

Office consultation

99384

Prevent visit new 12-17

99385

Prevent visit new 18–39

99386

Prevent visit new 40–64

99394

Prevent visit est 12-17

99395

Prevent visit est 18–39

99396

Prevent visit est 40–64

99401

Prev counsel indv 15 min

99402

Prev counsel indv 30 min

99403

Prev counsel indv 45 min

99404

Prev counsel indv 60 min

99411

Prev counsel grp 30 min

99412

Prev counsel grp 60 min

A4261

Cerv cap contracep

A4266

Diaphragm

A4267

Male condom

A4268

Female condom

A4269

Spermicide

G0027

Semen analysis pres/mot

G0433

HIV-1/HIV-2 ELISA technique; screen

H1010

Nonmed fam plan ed

J1050

Medroxyprogesterone acetate 1mg inject

J7297

Levonorgestrel IUD 52mg 3 yr (Liletta)

J7298

Levonorgestrel IUD 5 yr (Mirena)

J7300

copper IUD

J7301

Levonorgestrel IUD system (13.5mg)

*J7307

Etonogestrel IUD system (subderm)

*J7303

Contracept vaginal ring

*J7304

Contracept patch

J7307

Implanon impl system

J8499

Non-hormonal ECs (ex. Ulipristal)

Q0091

Pap smear

*S4989

Contracept IUD

*S4993

Hormonal oral BC pills/Emerg.contracept.

T1013

Oral language interp

*Indicates the HCPCS code requires an NDC dispensing unit and the quantity when billing MHCP.

Secondary MFPP Procedure Codes

Code/Range

Description

J0561

Inj penicillin G benz to 2.4 mil units

*J0696

Inj ceftriaxone sodium

*J8499**

Prescription drug, oral, NOS Use to report CDC recommended drugs for treatment of STIs when dispensed in the office, for example Amoxicillin, Cefixime, Ciprofloxacin, Clindamycin, Clotrimazole, Doxycycline, Fluconazole, Metronidazole, Nitrofurantoin, Ofloxacin, Sulfa-methoxazole/Trimethoprim, Terconazole. List the drug, dosage and number of tablets dispensed in the comments section of the services tab for that individual service line in MN–ITS

*Q0144

Azithromycin, oral capsule

10060

Incis & drain abscess

10140

Incis & drain hematoma

17110

Wart destruction

54050

Destroy penis lesions, chem

54056

Destroy penis lesions, cryo

56501

Destroy vulva lesions

57061

Destroy vaginal lesions

57452

Colposcopy cervix incl up/adj vagina

57454 - 57456

Colposcopy, w bio cervix

57460 - 57461

Colposcopy, w loop biop cervix conization

57510 - 57511

Cautery of cervix;

88305

Level IV - Surg path, gross and micro

88307

Level V - Surg path, gross and micro

*Indicates the HCPCS code requires an NDC when billing MHCP. Refer to HCPCS Codes Requiring NDC for additional information.

**In addition to the NDC, J8499 continues to require the drug, dosage and number of tablets dispensed in the comments.

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