Medicine and Surgery Section - Wisconsin.gov

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Appendix Category Female Genital System Nervous System Eye and Ocular Adnexa Auditory System Special Otorhinolaryngologic Services Appendix 15 (Continued) Proc. Code Description 57291 Construction of artificial vagina; without graft 57292 with graft 58400 Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; (separate procedure) 58410 with presacral sympathectomy 61490 Craniotomy for lobotomy, including cingulotomy 61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array 64573 Incision for implantation of neurostimulator electrodes; cranial nerve 67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) 67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material 67902 frontalis muscle technique with fascial sling (includes obtaining fascia) 67903 (tarso) levator resection or advancement, internal approach 67904 (tarso) levator resection or advancement, external approach 67906 superior rectus technique with fascial sling (includes obtaining fascia) 67908 conjunctivo-tarso-Muller’s muscle-levator resection (eg, Fasanella- Servat type) 67909 Reduction of overcorrection of ptosis 69714 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy 69715 with mastoidectomy 69717 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy 69718 with mastoidectomy 69930 Cochlear device implantation, with or without mastoidectomy 92510 Aural rehabilitation following cochlear implant (includes evaluation of aural rehabilitation status and hearing, therapeutic services) with or without speech processor programming 118 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005
Appendix 16 Prior Authorization Request Form (PA/RF) Completion Instructions for Physician Services Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligible recipients. Recipients are required to give providers full, correct, and truthful information for the submission of correct and complete claims for Medicaid reimbursement. This information should include, but is not limited to, information concerning eligibility status, accurate name, address, and Medicaid identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and is used for purposes directly related to Medicaid administration such as determining eligibility of the applicant or processing provider claims for reimbursement. The Prior Authorization Request Form (PA/RF), HCF 11018, is used by Wisconsin Medicaid and is mandatory when requesting PA. Failure to supply the information requested by the form may result in denial of Medicaid payment for the services. Providers may submit PA requests along with all applicable service-specific attachments, including the Prior Authorization/ Physician Attachment (PA/PA), HCF 11016, or the Prior Authorization/“J” Code Attachment (PA/JCA), HCF 11034, to Wisconsin Medicaid by fax at (608) 221-8616 or by mail to: Wisconsin Medicaid Prior Authorization Ste 88 6406 Bridge Rd Madison WI 53784-0088 The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the submitted claim(s). SECTION I — PROVIDER INFORMATION Element 1 — Name and Address — Billing Provider Enter the name and complete address (street, city, state, and zip code) of the billing provider. The name listed in this element must correspond with the Medicaid provider number listed in Element 4. No other information should be entered in this element since it also serves as a return mailing label. Element 2 — Telephone Number — Billing Provider Enter the telephone number, including the area code, of the office, clinic, facility, or place of business of the billing provider. Element 3 — Processing Type Enter processing type “117” (physician services, including family planning clinics, rural health clinics, and federally qualified health centers). The processing type is a three-digit code used to identify a category of service requested. Element 4 — Billing Provider’s Medicaid Provider Number Enter the eight-digit Medicaid provider number of the billing provider. The provider number in this element must correspond with the provider name listed in Element 1. Physician Services Handbook — Medicine and Surgery December 2005 119 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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Appendix 66 Wisconsin Medicaid and
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Page 74 and 75: Appendix Other Services Appendix 1
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Page 122 and 123: Appendix SECTION II — RECIPIENT I
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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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