C.M.R. 10, 144, ch. 101, ch. X, § 144-101-X-4, app 144-101-X-4.A

Current through 2024-51, December 18, 2024

Appendix 144-101-X-4.A - APPEAL RIGHTS

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

C.M.R. 10, 144, ch. 101, ch. X, § 144-101-X-4, app 144-101-X-4.A