E/M Services Code Only
If a patient comes in to discuss contraception options but no procedure is provided at that visit:
- If the discussion takes place during an annual preventive visit (99381–99387 or 99391–99397), it is included in the Preventive Medicine code. The discussion is not reported separately.
- If the discussion takes place during an E/M office or outpatient visit (99201–99215), an E/M services code may be reported if an E/M service (including history, physical examination, or medical decision making or time spent counseling) is documented. Link the E/M code to ICD-10-CM diagnosis code Z30.014 (encounter for initial prescription of intrauterine contraceptive device) or Z30.017 (encounter for initial prescription of implantable subdermal contraceptive) when applicable.
Reporting Contraceptive Services with Other Services
Under some circumstances, an Evaluation and Management (E/M) services code, a procedure code, and a HCPCS code may all be reported.