LOUISIANA MEDICAID PROGRAM ISSUED: 11/25/14 REPLACED: 10/16/14 CHAPTER 48: FAMILY PLANNING TAKE CHARGE PLUS APPENDIX A: DIAGNOSIS CODES PAGE(S) 9

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1 DIAGNOSIS CODES Take Charge Plus offers a limited benefit package of family planning and family planningrelated services which includes professional services, outpatient services, and laboratory/radiology and pharmaceutical services. With the exception of the services billed by pharmacists, all services must be submitted using an appropriate primary diagnosis. V01.6 VENEREAL DIS CONTACT V04.89 NEED PROPH VAC & INOCULAT OTH VIEL DZ V05.8 VACCIN FOR DISEASE NEC V25.01 PRESCRIP-ORAL CONTRACEPT V25.02 INITIATE CONTRACEPT NEC V25.03 ENCOUNTER EMERG CNTRAC PT CNSL & PRSC V25.04 CNSL&&INSTR NATURL FAM PLAN AVOID PG V25.09 CONTRACEPTIVE MANGMT NEC V25.11 ENC INSERTION IU CONTRACEPT DEVICE V25.12 ENC REMOVAL IU CONTRACEPTIVE DEVICE V25.13 ENC REMV REINS IU CONTRACEPT DEVICE V25.2 STERILIZATION V25.3 MENSTRUAL EXTRACTION V25.40 CONTRACEPT SURVEILL NOS V25.41 CONTRACEPT PILL SURVEILL Page 1 of 9

2 V25.42 IUD SURVEILLANCE V25.43 IMPLANTABLE SUBDERMAL CONTRACEPTIVE V25.49 CONTRACEPT SURVEILL NEC V25.5 INSERTION IMPLANTABLE SUBDERM CONTRACEPT V25.8 CONTRACEPTIVE MGMT NECS V25.9 CONTRACEPTIVE MANGMT NOS V26.51 TUBAL LIGATION STATUS V26.52 VASECTOMY STATUS V45.51 PRESENCE OF INTRA CONTRACEP DEVICE V45.52 PRESENCE OF SUBDERMAL CONTRACEPTIVE IMPLANT V45.59 PRESENCE OF OTHER CONTRACEPTIVE DEVICE V67.09 FLU EXAM FOLLOW OTH SURG V72.31 ROUTINE GYNECOLOGICAL EXAMINATION V72.60 LABORATORY EXAMINATION UNSPECIFIED GENITAL HERPES NOS HERPETIC VULVOVAGINITIS HERPETIC ULCER OF VULVA HERPETIC INFECT OF PENIS Page 2 of 9

3 GENITAL HERPES NEC MOLLUSCUM CONTAGIOSUM VIRAL WARTS, UNSPECIFIED CONDYLOMA ACUMINATUM PRIMARY GENITAL SYPHILIS PRIMARY ANAL SYPHILIS PRIMARY SYPHILIS NEC SECONDARY SYPH SKIN SYPHILITIC ADENOPATHY SYPHILITIC UVEITIS NOS SYPHILIT CHORIORETINITIS SYPHILITIC IRIDOCYCLITIS SYPHILITIC PERIOSTITIS SYPHILITIC HEPATITIS SECOND SYPH VISCERA NEC SECOND SYPHILIS RELAPSE ACUTE SYPHIL MENINGITIS SYPHILITIC ALOPECIA Page 3 of 9

4 SECONDARY SYPHILIS NEC SECONDARY SYPHILIS NOS EARLY SYPH LATENT RELAPS EARLY SYPHIL LATENT NOS 096 LATE SYPHILIS LATENT LATENT SYPHILIS NOS ACUTE GC INFECT LOWER GU GC (ACUTE) UPPER GU NOS GC CYSTITIS (ACUTE) GC PROSTATITIS (ACUTE) GC ORCHITIS (ACUTE) GC SEM VESICULIT (ACUTE) GC CERVICITIS (ACUTE) GC ENDOMETRITIS (ACUTE) ACUTE GC SALPINGITIS GC (ACUTE) UPPER GU NEC CHR GC INFECT LOWER GU CHANCROID Page 4 of 9

5 099.1 LYMPHOGRANULOMA VENEREUM UNSPECIFIED, NONSPECIFIC URETHRITIS CHLAMYDIA TRACHOMATIS UNSPECIFIED SITE CHLAMYDTRACHOMATIS INF ANUS&RECTUM CHLAMYDTRACHOMATIS INF LOWER GU SITES CHLAMYDTRACHOMATIS INF OTH GU SITES CHLAMYDTRACHOMAT INF UNSPEC GU SITE CHLAMYDTRACHOMATIS INF PERITONEUM CHLAMYDTRACHOMATIS INF OTH SPEC SITE CANDIDAL VULVOVAGINITIS CANDIDAL BALANITIS UROGENITAL TRICHOMON NOS TRICHOMONAL VAGINITIS TRICHOMONAL URETHRITIS TRICHOMONAL PROSTATITIS UROGENITAL TRICHOMON NEC CA IN SITU CERVIX UTERI Page 5 of 9

6 595.0 ACUTE CYSTITIS CHR INTERSTIT CYSTITIS CHRONIC CYSTITIS NEC TRIGONITIS CYSTITIS IN OTH DIS CYSTITIS CYSTICA IRRADIATION CYSTITIS CYSTITIS NEC CYSTITIS NOS URETHRAL ABSCESS URETHRITIS NOS URETHRAL SYNDROME NOS URETHRITIS NEC URIN TRACT INFECTION NOS HEMATURIA UNSPECIFIED GROSS HEMATURIA MICROSCOPIC HEMATURIA ORCHITIS/EPIDIDYMIT NOS Page 6 of 9

7 607.2 OTHER INFLAMMATORY DISORDERS OF PENIS MALE GENITAL DIS NEC AC SALPINGO-OOPHORITIS CHR SALPINGO-OOPHORITIS SALPINGO-OOPHORITIS NOS ACUTE PARAMETRITIS CHRONIC PARAMETRITIS AC PELV PERITONITIS-FEM FEM PELVIC PERITON ADHES CHR PELV PERITON NEC-FEM FEM PELV INFLAM DIS NEC FEM PELV INFLAM DIS NOS AC UTERINE INFLAMMATION CHR UTERINE INFLAMMATION UTERINE INFLAM DIS NOS CERVICITIS VAGINITIS NOS VAGINITIS IN OTH DISEASE Page 7 of 9

8 616.2 BARTHOLIN'S GLAND CYST BARTHOLIN'S GLND ABSCESS ABSCESS OF VULVA NEC ULCERATION OF VULVA NOS VULVAR ULCER IN OTH DIS MUCOSITIS OF CERVIX VAGINAL & VULVA OTH INFLAM DZ CERVIX VAGINA & VULVA FEMALE GEN INFLAM NOS MILD EYSPLASIA OF CERVIX MODERATE DYSPLASIA OF CERVIX LEUKOPLAKIA OF CERVIX NONINFECT VAG LEUKORRHEA DYSPAREUNIA FEM GENITAL SYMPTOMS NOS DYSURIA DYSFUNCTIONAL OR FUNCTIONAL UTERINE HEMORRHAGE NOS URINARY FREQUENCY URETHRAL DISCHARGE Page 8 of 9

9 ABDOMINAL PAIN, OTHER SPECIFIED SITE NONSPEC ABNORM PAP SMEAR CERV UNSPEC PAP SMEAR CERVIX WITH ASC-US PAP SMEAR CERVIX WITH ASC-H PAP SMEAR CERVIX WITH LGSIL PAP SMEAR CERVIX WITH HGSIL CERV HIGH RISK HPV DNA TEST POS PAP SMEAR CERV CYTOL EVIDENCE MALIG NONSPC ABN PAP SMER CERV UNSAT SMER OTH NONSPEC ABNORM PAP SMEAR CERV MECHANICAL COMPLICATION DUE TO IUD INFECTION AND INFLAMMATORY REACTION DUE TO IUD OTHER COMPLICATIONS OF IUD HEMORRHAGE COMPLICATING A PROCEDURE Page 9 of 9