Medicine and Surgery Section - Wisconsin.gov

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Legal Framework The following laws and regulations provide the legal framework for Wisconsin Medicaid and BadgerCare: • Federal Law and Regulation: ✓ Law — United States Social Security Act; Title XIX (42 US Code ss. 1396 and following) and Title XXI. ✓ Regulation — Title 42 CFR Parts 430-498 and Parts 1000-1008 (Public Health). • Wisconsin Law and Regulation: ✓ Law — Wisconsin Statutes: 49.43-49.499 and 49.665. ✓ Regulation — Wisconsin Administrative Code, Chapters HFS 101-109. Laws and regulations may be amended or added at any time. Program requirements may not be construed to supersede the provisions of these laws and regulations. 8 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005
To participate in Wisconsin Medicaid, providers are required to be certified by Wisconsin Medicaid as described in HFS 105, Wis. Admin. Code. General Information The Medicine and Surgery section of the Physician Services Handbook includes information for physician services providers (i.e., physicians, physician assistants, nurse practitioners, and nurse midwives) performing evaluation and management (E&M), medicine, and surgery services. It also includes information about covered services, prior authorization (PA) requirements, reimbursement methodology, and billing information that applies to fee-for-service Medicaid providers. It is essential that providers refer to the All- Provider Handbook for general information about certification, provider rights, documentation requirements, PA, claims submission, and other ongoing responsibilities. Certification To participate in Wisconsin Medicaid, providers are required to be certified by Wisconsin Medicaid as described in HFS 105, Wis. Admin. Code. Providers may refer to the Certification and Ongoing Responsibilities section of the All-Provider Handbook for general information about certification. Physician services providers who perform other services not mentioned in this handbook may refer to the Medicaid Web site or call Provider Services at (800) 947-9627 or (608) 221-9883 to obtain certification packets and more information about coverage limitations for other areas. All information on the Medicaid Web site may be downloaded. Physicians and Residents To be certified by Wisconsin Medicaid, physicians and residents are required to be licensed to practice medicine and surgery pursuant to ss. 448.05 and 448.07, Wis. Stats., and chs. Med 1, 2, 3, 4, 5, and 14, Wis. Admin. Code. Physicians are asked to identify their practice specialty at the time of Medicaid certification. Reimbursement for certain services is limited to physicians with specific specialties. To be reimbursed for psychiatric services (Current Procedural Terminology [CPT] codes 90801-90857, 90865-90899), physicians are required to be certified as a psychiatrist pursuant to HFS 105.22(1)(a), Wis. Admin. Code. Any Medicaid-certified physician may be reimbursed for substance abuse services. Physician Assistants To be Medicaid-certified, physician assistants are required to be licensed and registered pursuant to ss. 448.05 and 448.07, Wis. Stats., and chs. Med 8 and 14, Wis. Admin. Code. All physician assistants are required to be individually certified by Wisconsin Medicaid for their services to be reimbursed. Physician assistants cannot independently submit claims to Wisconsin Medicaid. Claims for services provided by a physician assistant must be submitted with the physician assistant’s nonbilling performing provider number and the supervising physician’s billing provider number. Nurse Practitioners Nurse practitioners should refer to the Nurse Practitioner Services Handbook for more information about certification requirements. Nurse Midwives Nurse midwives should refer to the Nurse Midwife Services Handbook for more information about certification requirements. HealthCheck Certification HealthCheck is Wisconsin Medicaid’s federally mandated program known nationally as Early and Periodic Screening, Diagnosis, and Physician Services Handbook — Medicine and Surgery December 2005 9 General Information
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Claims Submission 58 Wisconsin Medi
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Reimbursement • Confirming or rev
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Reimbursement about whether a speci
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Reimbursement 64 Wisconsin Medicaid
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Appendix 66 Wisconsin Medicaid and
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Appendix Surgery Services Appendix
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Appendix Medicine Services (Continu
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Appendix Other Services Appendix 1
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Appendix (This page was intentional
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ABORTION CERTIFICATION STATEMENTS P
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STERILIZATION INFORMED CONSENT FORM
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DEPARTMENT OF HEALTH AND FAMILY SER
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Appendix Category Musculoskeletal S
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Appendix Category Musculoskeletal S
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Appendix Category Female Genital Sy
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Appendix SECTION II — RECIPIENT I
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Appendix PRIOR AUTHORIZATION / PHYS
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PRIOR AUTHORIZATION / PHYSICIAN ATT
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PRIOR AUTHORIZATION / “J” CODE
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PRIOR AUTHORIZATION / PHYSICIAN OTO
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Appendix Health Professional Shorta
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Appendix HPSA Name County ZIP Codes
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Appendix The following table lists
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DECLARATION OF SUPERVISION FOR NONB
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Appendix HCPCS Code* Drug Name Diag
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Index Organ Transplants, 44 Provide
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Medicine and Surgery Section - Wisconsin.gov

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