Benefits Grid (ben Grid) - Medi-Cal
ben grid1Benefits GridPage updated: August 2020This Clinical Services Benefits Grid includes the codes for procedures, medications and contraceptive supplies that arereimbursable under the Family Planning, Access, Care and Treatment (Family PACT) Program. For codes for themanagement of complications (1) that may arise from the use of a contraceptive method, refer to the Benefits: FamilyPlanning section in this manual.Family Planning ServicesICD-10-CM Codesand DescriptionProceduresZ30.012 (Encounterfor prescription ofemergencycontraception)‹‹None››Z30.09 (Encounterfor generalcounseling andadvice oncontraception (33)‹‹None››Family PACT – Benefits GridLaboratory ¿81025: Urinepregnancy test81025: Urinepregnancy test tionJ3490U5: Ulipristal acetate(ECP)J3490U6: Levonorgestrel(ECP)‹‹None››
ben grid2Page updated: August 2020Family Planning Services (continued)ICD-10-CM Codesand DescriptionZ30.011 (Initialprescription,contraceptive pills)Procedures99000: Handlingand/or conveyanceof blood specimento unaffiliated labZ30.41 (Surveillance,contraceptive pills)Laboratory ¿81025: Urinepregnancy testSuppliesMedicationA4267: MalecondomS4993: OralContraceptivesA4268: InternalcondomS5000/S5001: Estradiol(requires additional ICD10-CM code N92.1)Spermicides:A4269U1: Gel, jelly,cream, or foamJ3490U5: Ulipristal acetate(ECP)A4269U2:SuppositoryJ3490U6: Levonorgestrel(ECP)A4269U3: VaginalfilmA4269U4: SpongeS5199: LubricantFamily PACT – Benefits Grid
ben grid3Page updated: August 2020Family Planning Services (continued)ICD-10-CM Codesand DescriptionZ30.015 Initialprescription, vaginalringProcedures99000: Handlingand/or conveyanceof blood specimento unaffiliated labZ30.44 Surveillance,vaginal ringZ30.016 Initialprescription,transdermal patchZ30.45 Surveillance,transdermal patchLaboratory ¿81025: Urinepregnancy testSuppliesA4267: Male condomA4268: InternalcondomJ7304: Contraceptivetransdermal patchJ7303: Contraceptivevaginal ringSpermicides:A4269U1: Gel, jelly,cream, or foamA4269U2:SuppositoryA4269U3: VaginalfilmA4269U4: SpongeS5199: LubricantFamily PACT – Benefits GridMedicationS5000/S5001: Estradiol(requires additional ICD10-CM code N92.1)J3490U5: Ulipristalacetate (ECP)J3490U6: Levonorgestrel(ECP)
ben grid4Page updated: August 2020Family Planning Services (continued)ICD-10-CM Codesand DescriptionZ30.013 (Initialprescription, injectablecontraceptive)Procedures99000: Handlingand/or conveyanceof blood specimento unaffiliated labZ30.42 (Surveillance,injectablecontraceptive)Laboratory ¿81025: Urinepregnancy testSuppliesA4267: Male condomA4268: InternalcondomSpermicides:A4269U1: Gel, jelly,cream, or foamA4269U2:SuppositoryA4269U3: VaginalfilmA4269U4: SpongeS5199: LubricantFamily PACT – Benefits GridMedicationS5000/S5001: Estradiol(requires additional ICD10-CM code N92.1)J3490U5: Ulipristalacetate (ECP)J3490U6: Levonorgestrel(ECP)
ben grid5Page updated: August 2020Family Planning Services (continued)ICD-10-CM CodesZ30.017 (Initialprescription,subdermal implant)Procedures11976: Removal11981: InsertionZ30.46 (Surveillance,subdermal implant)Laboratory ¿81025: Urinepregnancy testSupplies11976UA: RemovalA4267: MalecondomMedicationJ7307:Etonogestrel implantS5000/S5001: Estradiol(requires ICD-10-CM codeN92.1)99000: Handlingand/or conveyanceof blood specimento unaffiliated labA4268: Internalcondom73060: X-rayhumerus (34)A4269U1: Gel,J3490U6: Levonorgestrelcream, jelly, or foam (ECP)76882: Ultrasound,limited, joint orother nonvascularextremitystructure(s) (34)A4269U2:SuppositorySpermicidesA4269U3: VaginalfilmA4269U4: SpongeS5199: LubricantFamily PACT – Benefits GridJ3490U5: Ulipristal acetate(ECP)
ben grid6Page updated: August 2020Family Planning Services (continued)ICD-10-CM CodesProceduresZ30.430 (Insertion,intrauterinecontraceptive device)58300: InsertionZ30.431 (Routinechecking, intrauterinecontraceptive device)Z30.432 (Removal ofintrauterinecontraceptive device)Z30.433 (Removaland reinsertion ofintrauterinecontraceptive device)Laboratory ¿81025: Urinepregnancy test58301: Removal74018: X-rayabdomen, 1 view(6)76830: TransvagUS (6)Supplies58300UA: Insertion99000: Handlingand/or conveyanceof blood specimento unaffiliated labJ7297: Levonorgestrel IU(liletta), 52 mg58301UA: Removal85013, 85014:HematocritA4267: Malecondom85018: HemoglobinA4268: InternalcondomSpermicides:76857: US pelviclimited or F/U (6)MedicationA4269U1: gel, jelly,cream or foamA4269U2:SuppositoryA4269U3: VaginalfilmJ7298: Levonorgestrel IU(mirena), 52 mgJ7300: Intrauterine coppercontraceptiveJ7301: Levonorgestrel IU(skyla),13.5 mgJ3490U5: Ulipristal acetate(ECP)J3490U6: Levonorgestrel(ECP)J7296: Levonorgestrel IU(kyleena) 19.5 mgA4269U4: SpongeS5199: LubricantFamily PACT – Benefits GridS5000/S5001: Estradiol(requires ICD-10-CM codeN92.1)
ben grid7Page updated: August 2020Family Planning Services (continued)ICD-10-CM CodesZ30.018 (Initialprescription of othercontraceptives (maleor female barrierand/or spermicide)Z30.49 (Surveillanceof othercontraceptives (maleor female barriersand/or spermicide)ProceduresLaboratory ¿57170: Diaphragm/ 81025: Urinecervical cap fittingpregnancy test99000: Handlingand/or conveyanceof blood specimento unaffiliated labSuppliesMedication11976UA: RemovalJ3490U5: Ulipristal acetate(ECP)A4267: MalecondomA4268: InternalcondomSpermicidesA4269U1: Gel,cream, jelly, or foamA4269U2:SuppositoryA4269U3: VaginalfilmA4269U4: SpongeS5199: LubricantFamily PACT – Benefits GridJ3490U6: Levonorgestrel(ECP)
ben grid8Page updated: August 2020Family Planning Services (continued)ICD-10-CM CodesProceduresLaboratory ¿Z30.02 (Counseling‹‹None››and instruction innatural family planningto avoid pregnancy)81025: Urinepregnancy test‹‹None››81025: Urinepregnancy testZ31.61 (Procreativecounseling and adviceusing natural familyplanning) (34)Family PACT – Benefits GridSuppliesBBT (26)MedicationJ3490U5: Ulipristal acetate(ECP)J3490U6: Levonorgestrel(ECP)BBT (26)‹‹None››
ben grid9Page updated: August 2020Family Planning Services (continued)ICD-10-CM CodesZ30.09 (Encountergeneral counselingand advice oncontraception(sterilization)Procedures99000: Handlingand/or conveyanceof blood specimento unaffiliated labLaboratory ¿81025: Urinepregnancy testPreoperative tests:81000: UA dipstickw/microscopyZ01.812 (28)(Encounter forpre-procedural labexam (femalesterilization)81001: UAautomatedw/microscopy81002: UA dipstickw/out microscopy81003: UAautomated w/outmicroscopy85013: Spun Hct85014: Hct85018: Hemoglobin85025: Auto CBCw/auto diff. WBCFamily PACT – Benefits �›
ben grid10Page updated: August 2020Family Planning Services (continued)ICD-10-CM CodesZ30.09 (Encountergeneral counselingand advice oncontraception(sterilization)Procedures99000: Handlingand/or conveyanceof blood specimento unaffiliated labLaboratory ¿85027: Auto CBCw/out differential85002: Bleeding time(27)85610: Prothrombintime (27)Z01.812 (28)(Encounter forpre-procedural labexam (femalesterilization)Family PACT – Benefits Grid85730:thromboplastin ne››
ben grid11Page updated: August 2020Family Planning Services (continued)ICD-10-CM CodesProceduresZ01.818 (Encounterfor other preprocedural exam(female sterilization)(28)71046: Chest Xray (7)Laboratory ��‹‹None››88302: Surgical path.(two specimens)A4264 50/52:Intratubal 0: ECG (7)93307:Echocardiography(7) (27)Z30.2 (Encounter forsterilization (female)58565:Hysteroscopicsurgical placementof micro-insert(s)58600: Mini lap TL58615: Mini lap TLwith clip58661:Laparoscopy withremoval of ly PACT – Benefits Grid58565UA/UB:Hysteroscopic surgsupplies58600UA/UB: MiniLap TL58615UA/UB: MiniLap with clip58661UA/UB:Laparoscopy withremoval of adnexalstructures
ben grid12Page updated: August 2020Family Planning Services (continued)ICD-10-CM CodesZ30.2 (Encounter forsterilization (female)Procedures58671:Laparoscopicsterilization withring or clip58700:Salpingectomy,complete or partial58555:Hysteroscopy,diagnostic (29)Family PACT – Benefits GridLaboratory complete or partial58671UA/UB:Laparoscopicsterilization with ringor clipMedication‹‹None››
ben grid13Page updated: August 2020Family Planning Services (continued)ICD-10-CM CodesZ98.51 (Tubal hy (30)58340:Catheterizationand introduction ofsaline or contrastmaterial for salineinfusionsonohysterography [SIS] orhysterosalpingography (31)Laboratory ¿‹‹None››SuppliesA4267: MalecondomJ3490U5: Ulipristalacetate (ECP)A4268: InternalcondomJ3490U6: Levonorgestrel(ECP)Spermicides:A4269U1: Gel, jelly,cream or foamA4269U2:SuppositoryA4269U3: VaginalfilmA4269U4: SpongeS5199: LubricantFamily PACT – Benefits GridMedication
ben grid14Page updated: August 2020Family Planning Services (continued)ICD-10-CM CodesProceduresZ01.812 (Encounterfor pre-procedural labexam (malesterilization) (28)99000: Handlingand/or conveyanceof blood specimento unaffiliated labLaboratory ¿Preoperative tests:81000: UA dipstickw/microscopy81001: UAautomatedw/microscopy81002: UA dipstickw/out microscopy81003: UAautomated w/outmicroscopy85013: Spun Hct85014: Hct85018: Hemoglobin85025: Auto CBCw/auto diff. WBC85027: Auto CBCw/out differentialFamily PACT – Benefits �›
ben grid15Page updated: August 2020Family Planning Services (continued)ICD-10-CM CodesZ30.2 (Encounter forsterilization (male)Z98.52 (Vasectomystatus)ProceduresLaboratory ¿55250: Vasectomy88302: Surgical path(two 55250UA/UB:VasectomyA4267: MalecondomA4268: InternalcondomSpermicides:A4269U1: Gel, jelly,cream or foamA4269U2:SuppositoryA4269U3: VaginalfilmA4269U4: SpongeS5199: LubricantPost vasectomy semen analysis is included in the global fee for vasectomy.Family PACT – Benefits GridMedication‹‹None››‹‹None››
ben grid16Page updated: August 2020Reproductive Health Screening TestsThese services may be provided as clinically indicated. These services are not reimbursable for Z30.012, Z30.09 andZ31.61. For more information, refer to the Benefits: Family Planning section in this manual.Reproductive Health Screening TestsCPT Codes86592 (VDRL, RPR)Reflex Testing (based on a positive screening testresult)86780 TP-confirmatory test; if positive, 86593 isrequiredRestrictions‹‹None››86593 Syphilis test,non-treponemal antibody; quantitative86701 (HIV-1 antibody)86702 (HIV-2 antibody)86703 (HIV-1 and HIV-2antibodies, single result)86689 HIV confirmatory test(e.g. Western Blot)OR86701 and 86702 differentiation assayAND87389 (HIV-1 antigen(s),with HIV-1 andHIV-2 antibodies, singleresult)87806 (HIV-1 antigen(s),with HIV-1 and HIV-2antibodies)Family PACT – Benefits Grid87535 HIV – NAAT(if differentiation assay results are negative orindeterminate)86689 limited to HIVantibody
ben grid17Page updated: August 2020Reproductive Health Screening Tests (continued)CPT Codes87491 § (NAAT – Chlamydia)87591 § (NAAT – Gonorrhea)Reflex Testing (based on a positive screening testresult)NoneRestrictionsRefer to the ChlamydiaTrachomatis (CT) andNeisseria gonorrhoeae(GC) screening guidelinesCT and GC screening tests for females 25 years of age and older and males of all ages require an additional ICD-10-CMcode. Females under 25 years of age may require an additional ICD-10-CM code. For additional information, refer to theBenefits: Family Planning section in this manual.Family PACT – Benefits Grid
ben grid18Page updated: August 2020Family Planning-Related Services: Cervical Cancer ScreeningThe following laboratory tests are covered when clinically indicated and provided as part of, or as a follow-up to, a familyplanning visit. These tests must be ordered in conjunction with a family planning visit. These tests are billed with theappropriate family planning ICD-10-CM diagnosis code and may require an additional diagnosis code. Providers may referto the Laboratory Services section in this manual.Cervical CytologyCPT Code88142DescriptionLBC, manual screen88143LBC, manual screen and rescreen88147Smear, automated screen88148Smear, automated screen, manual re-screen88164Smear, Bethesda, manual screen88165Smear, Bethesda, manual screen, re-screenSmear, Bethesda, manual screen, computer re-screen8816788174LBC, automated screen88175LBC, automated screen, manual re-screenAdditional Information: Refer to the Benefits: Family Planning-Related Services section in this manual for additionalinformation and claim requirements.Family PACT – Benefits Grid
ben grid19Page updated: August 2020Human Papillomavirus (HPV) TestingCPT Code87624DescriptionHPV. high-risk types87625HPV, 16/18 genotypeAdditional Information: Refer to the Benefits: Family Planning-Related Services section in this manual for additionalinformation and claim requirements.Family PACT – Benefits Grid
ben grid20Page updated: August 2020Family Planning-Related Services: Management of Sexually Transmitted Infections(STIs)Treatment or diagnostic testing of specified sexually transmitted infections (STIs) may be provided as clinically indicated.For services to manage a complication of family planning-related treatment, refer to the Benefits: Family Planning-RelatedServices section in this manual. (11)Family Planning-Related Services (9)ICD-10-CM Code and DescriptionZ20.2 (Use Z20.2 for diagnosis andtreatment of an asymptomatic partnerexposed to active case of chlamydia,gonorrhea, syphilis, or ��›Laboratory‹‹None››None87205: Gram stain Nonesymptomatic males onlyA56.01 (CT cystitis and urethritis (M/F)A56.09 (Other chlamydial infection lowerof genitourinary tract) (F)A56.3 (CT anus/rectum) (M/F)A56.4 (CT pharynx) (M/F)Presumptive DxN34.2 (Other urethritis) (M)N45.3 (Epididymo-orchitis) (M)Family PACT – Benefits Grid87491: CT, amplifiedprobe techniqueSupplies‹‹None››Medications (8)‹‹None››AzithromycinDoxycycline
ben grid21Page updated: August 2020Family Planning-Related Services (9)ICD-10-CM Code and DescriptionN72 (Inflammatory disease of cervixuteri) (F)N89.8 (Other specified non-inflammatorydisorders of vagina) (F)N94.10 Unspecified dyspareunia (F)N94.11 Superficial (introital) dyspareunia(F)Deep dyspareunia (F)N94.12 Other specified dyspareunia (F)N89.8 (Other specified non-inflammatorydisorders of vagina) (F)N94.10 Unspecified dyspareunia (F)N94.11 Superficial (introital) dyspareunia(F)N94.12 (Deep dyspareunia) (F)Family PACT – Benefits GridProceduresNoneLaboratory87205: Gram stain symptomatic males only87491: CT, amplifiedprobe techniqueSuppliesNoneMedications (8)AzithromycinDoxycycline
ben grid22Page updated: August 2020Family Planning-Related Services (9) (continued)ICD-10-CM Code and DescriptionN94.19 (Other specified dyspareunia) (F)N94.89 (Other conditions associated withfemale genital organs) (F)R30.0 (Dysuria) (M/F)R30.9 Painful micturition, unspecified)(M/F)Z20.2 (STI (CT)-exposed partner) (M/F)Family PACT – Benefits GridProceduresNoneLaboratory87205: Gram stain symptomatic males only87491: CT, amplifiedprobe techniqueSuppliesMedications (8)NoneAzithromycinDoxycycline
ben grid23Page updated: August 2020Family Planning-Related Services (9) (continued)ICD-10-CM Code and DescriptionProceduresA54.01 (Gonorrhea GC cystitis and urethritis, Noneunspecified) (M/F)A54.5 (GC pharyngitis) (M/F)A54.6 (GC anus/rectum) (M/F)A54.22 (GC prostatitis) (M)A54.03 (GC cervicitis, unspecified) (F)Presumptive DxN34.2 (Other urethritis) (M)N45.3 (Epididymo-orchitis) (M)N72 (Inflammatory disease of cervix uteri)(F)N89.8 (Other specified non-inflammatorydisorders of vagina) (F)N94.10 (Unspecified dyspareunia) (F)N94.11 (Superficial (introital) dyspareunia)(F)N94.12 (Deep dyspareunia) (F)N94.19 (Other specified dyspareunia) (F)N94.89 (Other conditions associated withfemale genital organs) (F)R30.0 (Dysuria) (M/F)R30.9 (Painful micturition, unspecified) (M/F)Z20.2 (STI (GC)-exposed partner) (M/F)Family PACT – Benefits GridLaboratory87205: Gram stain –symptomatic males only87591: GC, amplifiedprobe techniqueSuppliesMedications (8)NoneAzithromycinCefiximeCeftriaxoneDoxycycline
ben grid24Page updated: August 2020Family Planning-Related Services (9) (continued)ICD-10-CM Code and DescriptionHerpes (genital only)ProceduresNoneLaboratoryAdditional RestrictionsApply (12)A60.01 (Herpes penis)A60.04 (HSV Vulvovaginitis)87255: HSV culturePresumptive Dx87529: HSV NAATSuppliesMedications (8)NoneAcyclovirN48.5 (Ulcer of penis)N76.6 (Ulceration of vulva)PID (uncomplicated outpatient only)N70.03 Acute salpingitis and oophoritisN70.93 Salpingitis and oophoritis,unspecifiedN94.10 Unspecified dyspareunia (F)N94.11 Superficial (introital) dyspareunia(F)N94.12 Deep dyspareunia (F)N94.19 Other specified dyspareunia (F)N94.89 Other conditions associated withfemale genital organs (F)99000: Handling 85025: CBC/diffand/orconveyance of 85651: ESRblood specimenfor transfer to85652: ESRlab87491: CT, amplifiedprobe technique87591: GC, amplifiedprobe itin idFamily PACT – Benefits Grid
ben grid25Page updated: August 2020Family Planning-Related Services (9) (continued)ICD-10-CM Code and DescriptionSyphilisA51.0 Primary genital (M/F)A51.31 Condyloma latum (M/F)A51.39 Other, secondary (M/F)A51.5 Early, latent (M/F)A52.8 Late, latent (M/F)A53.0 Latent, unspecified (M/F)Presumptive DxN48.5 Ulcer of penisN76.6 Ulceration of vulvaZ20.2 STI (Syphilis) – exposed partnerFamily PACT – Benefits GridProceduresLaboratorySupplies99000: Handling 86593: Syphilis test, non- Noneand/ortreponemal antibody;conveyance of quantitative (15)blood specimenfor transfer tolabMedications (8)Penicillin Gbenzathine longacting – injectionDoxycycline
ben grid26Page updated: August 2020Family Planning-Related Services (9) (continued)ICD-10-CM Code and uppliesMedications (8)83986: pH (females only) NoneMetronidazoleA59.01 (Trichomonal vulvo-vaginitis)A59.03 (Trich. cystitis and urethritis)N76.0 (Acute vaginitis)87210: Wet mountPresumptive DxT. vaginalisN34.2 (Other urethritis) (M)Z20.2 STI ([Trichomoniasis] – exposedpartner) (M/F)87661: NAAT –(females only)87808:T. vaginalis immunoassay(females only)Q0111: Wet mountFamily PACT – Benefits GridTinidazole (16)
ben grid27Page updated: August 2020Family Planning-Related Services (9) (continued)ICD-10-CM Code and DescriptionVulvovaginitisProceduresNoneB37.3 Candidiasis of vulva and vaginaN76.0 Acute vaginitisLaboratorySuppliesMedications (8)83986: pH (females only) NoneClotrimazole87210: Wet mountFluconazoleQ0111 Wet mountMiconazoleTerconazole(27)ClindamycinWarts (genital only)A63.0 (Anogenital [venereal] warts)(M/F)B08.1 (Molluscum) (M/F)B07.9 (Viral wart, unspecified) (M/F)54050: Destructionof penile lesion;chemical (14)88305: Surgical path formales 4056: Destructionof penile lesion; cryo 88305: Surgical path for(14)females (17)54100UA54100: Biopsy ofpenis (17)57061UA56501UA56605UAFamily PACT – Benefits Grid
ben grid28Page updated: August 2020Family Planning-Related Services (9) (continued)ICD-10-CM Code and DescriptionWarts (genital only)ProceduresLaboratory56501:88305: Surgical path forDestructionmales (17)A63.0 (Anogenital [venereal] warts) (M/F) vulvar lesion (14)B08.1 (Molluscum) (M/F)B07.9 (Viral wart, unspecified) (M/F)57061:88305: Surgical path forDestructionfemales (17)vaginal lesion(14)56605: Biopsy,vulva (17)Family PACT – Benefits GridSuppliesMedications (8)54050UA lox
ben grid29Page updated: August 2020Family Planning-Related Services: Management of Urinary Tract Infection (UTI)Treatment or diagnostic tests for the management of urinary
Family Planning-Related Services: Cervical Cancer Screening The following laboratory tests are covered when clinically indicated and provided as part of, or as a follow-up to, a family planning visit. These tests must be ordered in conjunction with a family planning visit. These tests are billed with the
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55 11-13 Crisis Referral Not Medi-Cal Eligible 55 14-16 MHS Contract Admin. Not Medi-Cal Eligible 55 17-19 Discounted MH Outreach Not Medi-Cal Eligible 55 21-23 SPMP Case Management Not Medi-Cal Eligible 55 24-26 SPMP Program Planning Not Medi-Cal Eligible 55
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