Medicine and Surgery Section - Wisconsin.gov

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Appendix Category Musculoskeletal System (Continued) Respiratory System Appendix 15 (Continued) Proc. Code Description 21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement 21244 Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) 21245 Reconstruction of mandible or maxilla, subperiosteal implant; partial 21246 complete 21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia) 21248 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial 21249 complete 21255 Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) 21256 Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia) 21260 Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach 21261 combined intra- and extracranial approach 21263 with forehead advancement 21267 Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach 21268 combined intra- and extracranial approach 21270 Malar augmentation, prosthetic material 21275 Secondary revision of orbitocraniofacial reconstruction 21280 Medial canthopexy (separate procedure) 21282 Lateral canthopexy 21295 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach 21296 intraoral approach 21299 Unlisted craniofacial and maxillofacial procedure 21740 Reconstructive repair of pectus excavatum or carinatum; open 30120 Excision or surgical planing of skin of nose for rhinophyma 30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip 30410 complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip 30420 including major septal repair 30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work) 30435 intermediate revision (bony work with osteotomies) 30450 major revision (nasal tip work and osteotomies) 32851 Lung transplant, single; without cardiopulmonary bypass [transplant center obtains PA, not physician] 32852 with cardiopulmonary bypass [transplant center obtains PA, not physician] 32853 Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass [transplant center obtains PA, not physician] 32854 with cardiopulmonary bypass [transplant center obtains PA, not physician] 116 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005
Category Cardiovascular System Hemic and Lymphatic System Digestive System Male Genital System Appendix 15 (Continued) Proc. Code Description 33935 Heart-lung transplant with recipient cardiectomy-pneumonectomy [transplant center obtains PA, not physician] 33945 Heart transplant, with or without recipient cardiectomy [transplant center obtains PA, not physician] 37650 Ligation of femoral vein 38240 Bone marrow or blood-derived peripheral stem cell transplantation; allogenic [transplant center obtains PA, not physician] 38241 autologous [transplant center obtains PA, not physician] 42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) 42950 Pharyngolplasty (plastic or reconstructive operation on pharynx) 43644 Laparascopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (Roux limb 150 cm or less) 43645 with gastric bypass and small intestine reconstruction to limit absorption 43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty 43843 other than vertical-banded gastroplasty 43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (less than 100 cm) Roux-en-Y gastroenterostomy 43847 with small intestine reconstruction to limit absorption 43848 Revision of gastric restrictive procedure for morbid obesity (separate procedure) 44135 Intestinal allotransplantation; from cadaver donor 44136 from living donor 44137 Removal of transplanted intestinal allograft, complete 47135 Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age [transplant center obtains PA, not physician] 47136 heterotopic, partial or whole, from cadaver or living donor, any age [transplant center obtains PA, not physician] 47399 Unlisted procedure, liver (PA required only for liver-small intestine transplant) [transplant center obtains PA, not physician] 48160 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells [transplant center obtains PA, not physician] 48554 Transplantation of pancreatic allograft [transplant center obtains PA, not physician] 54400 Insertion of penile prosthesis; non-inflatable (semi-rigid) 54416 Removal and replacement of non-inflatable (semi-rigid) or inflatable (selfcontained) penile prosthesis at the same operative session 54417 Removal and replacement of non-inflatable (semi-rigid) or inflatable (selfcontained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue Physician Services Handbook — Medicine and Surgery December 2005 117 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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Reimbursement 64 Wisconsin Medicaid
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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 116 and 117: Appendix Category Musculoskeletal S
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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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DEPARTMENT OF HEALTH AND FAMILY SER
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Appendix HCPCS Code* Drug Name Diag
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Index Organ Transplants, 44 Provide
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