Medicine and Surgery Section - Wisconsin.gov

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Appendix Category Musculoskeletal System Appendix 15 (Continued) Proc. Code Description 21010 Arthrotomy, temporomandibular joint 21050 Condylectomy, temporomandibular joint (separate procedure) 21060 Meniscectomy, partial or complete, temporomandibular joint (separate procedure) 21070 Coronoidectomy (separate procedure) 21079 Impression and custom preparation; interim obturator prosthesis 21080 definitive obturator prosthesis 21081 mandibular resection prosthesis 21082 palatal augmentation prosthesis 21083 palatal lift prosthesis 21084 speech aid prosthesis 21085 oral surgical splint 21086 auricular prosthesis 21087 nasal prosthesis 21088 facial prosthesis 21089 Unlisted maxillofacial prosthetic procedure 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material) 21121 sliding osteotomy, single piece 21122 sliding osteotomies, two or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) 21123 sliding, augmentation with interpositional bone grafts (includes obtaining autografts) 21125 Augmentation, mandibular body or angle; prosthetic material 21127 with bone graft, onlay or interpositional (includes obtaining autograft) 21137 Reduction forehead; contouring only 21138 contouring and application of prosthetic material or bone graft (includes obtaining autograft) 21139 contouring and setback of anterior frontal sinus wall 21141 Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft 21142 two pieces, segment movement in any direction, without bone graft 21143 three or more pieces, segment movement in any direction, without bone graft 21145 single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) 21146 two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) 21147 three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) 21150 Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) 21151 any direction, requiring bone grafts (includes obtaining autografts) 114 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005
Category Musculoskeletal System (Continued) Appendix 15 (Continued) Proc. Code Description 21154 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autographs); without LeFort I 21155 with LeFort I 21159 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I 21160 with LeFort I 21172 Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) 21175 Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) 21179 Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) 21180 with autograft (includes obtaining grafts) 21181 Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial 21182 Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm 21183 total area of bone grafting greater than 40 sq cm but less than 80 sq cm 21184 total area of bone grafting greater than 80 sq cm 21188 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) 21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft 21194 with bone graft (includes obtaining graft) 21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation 21196 with internal rigid fixation 21198 Osteotomy, mandible, segmental 21206 Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 reduction 21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) 21215 mandible (includes obtaining graft) 21230 Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) 21235 ear cartilage, autogenous, to nose or ear (includes obtaining graft) 21240 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) 21242 Arthroplasty, temporomandibular joint, with allograft Physician Services Handbook — Medicine and Surgery December 2005 115 Appendix
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Physician Services Medicine and Sur
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T Table of Contents Preface .......
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Telemedicine ......................
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Health Professional Shortage Areas
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Legal Framework The following laws
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General Information Treatment (EPSD
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General Information Category III Co
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General Information collecting the
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General Information • The current
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Evaluation and Management reimburse
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Evaluation and Management in an out
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Evaluation and Management 22 Wiscon
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Medicine Services System [HCPCS] co
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Medicine Services In cases where mo
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Medicine Services documentation in
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Medicine Services Providers of ment
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Medicine Services Substance Abuse S
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Surgery Services Appendix 10 of thi
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Surgery Services Cataract Surgery W
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Surgery Services and the insertion
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Surgery Services Note: A telephone
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Surgery Services • Sterilization.
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Surgery Services live with her sinc
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Surgery Services by a multi-discipl
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Prescription Requirements Prescribe
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Prescription Requirements Approval
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Prescription Requirements prescribe
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Prescription Requirements 54 Wiscon
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Claims Submission adjustment reques
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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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Page 70 and 71: Appendix Surgery Services Appendix
Page 72 and 73: Appendix Medicine Services (Continu
Page 74 and 75: Appendix Other Services Appendix 1
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Page 98 and 99: ABORTION CERTIFICATION STATEMENTS P
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Page 104 and 105: DEPARTMENT OF HEALTH AND FAMILY SER
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Page 118 and 119: Appendix Category Musculoskeletal S
Page 120 and 121: Appendix Category Female Genital Sy
Page 122 and 123: Appendix SECTION II — RECIPIENT I
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Page 152 and 153: Appendix Health Professional Shorta
Page 154 and 155: Appendix HPSA Name County ZIP Codes
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Page 160 and 161: Appendix The following table lists
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DEPARTMENT OF HEALTH AND FAMILY SER
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Appendix (This page was intentional
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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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