Medicine and Surgery Section - Wisconsin.gov

More documents

Recommendations

Info

DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSIN Division of Health Care Financing HCF 11019 (Rev. 06/03) WISCONSIN MEDICAID PRIOR AUTHORIZATION / PHYSICIAN OTOLOGICAL REPORT (PA/POR) Providers may submit prior authorization (PA) requests by fax to Wisconsin Medicaid at (608) 221-8616 or providers may send the completed form with attachments to: Wisconsin Medicaid, Prior Authorization, Suite 88, 6406 Bridge Road, Madison, WI 53784-0088. Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Physican Otological Report (PA/POR) Completion Instructions (HCF 11019A). SECTION I — PROVIDER INFORMATION 1. Name — Physician 2. Physician’s UPIN, Medicaid Provider Number, or License Number 3. Address — Physician (Street, City, State, Zip Code) 4. Telephone Number — Physician SECTION II — RECIPIENT INFORMATION 5. Name — Recipient (Last, First, Middle Initial) 6. Date of Birth — Recipient 7. Address — Recipient (Street, City, State, Zip Code) 8. Recipient Medicaid Identification Number 9. Sex — Recipient # Male # Female SECTION III — DOCUMENTATION 10. Medical History of Hearing Loss 11. Pertinent Otological Findings Normal Problems (describe) (check below) Right: Canal # ________________ Ear Drum # ________________ Middle Ear # ________________ Left: Canal # ________________ Ear Drum # ________________ Middle Ear # ________________ 13. Clinical Diagnosis of Hearing Status 14. Medical, Cognitive, or Developmental Problems 15. Physician’s Recommendations (check all applicable) 12. Describe Additional Findings (e.g., results of special studies, such as caloric and postural tests) # I have medically evaluated this patient and refer him / her for a hearing instrument evaluation as follows: # One or more of the situations listed below applies to this patient. Therefore, as required by Medicaid regulations, I refer this patient to an audiologist for a hearing instrument evaluation / diagnosis: # The patient is 21 years of age or under. # The patient is behaviorally or cognitively impaired. # The patient has other special needs requiring a comprehensive evaluation or specialized diagnostic tools of a clinically certified evaluation. # None of the above situations applies to this patient. Either an audiologist or a hearing instrument specialist may provide the hearing instrument evaluation. # A home hearing test is required. SIGNATURE — Physician Date Signed
Appendix 25 Health Professional Shortage Area-Eligible Procedure Codes and ZIP Codes Wisconsin Medicaid provides enhanced reimbursement for selected procedures for primary care providers and emergency medicine providers who either provide care within areas designated by the federal Health Resources and Services Administration (HRSA) as a Health Professional Shortage Area (HPSA) or who provide care for recipients who reside in these areas. Providers may submit claims with HPSA modifier “AQ” (Physician providing a service in a HPSA) to receive a 50 percent bonus incentive. While the modifier is defined for physicians only, any Medicaid HPSA-eligible provider may use them with the following procedure codes. Health Professional Shortage Area-Eligible Procedure Codes Category Procedure Code(s) Evaluation and Management Services* New Patient 99201, 99202, 99203, 99204, 99205 Established Patient 99211, 99212, 99213, 99214, 99215 Emergency Department 99281, 99282, 99283, 99284, 99285 Newborn Care 99431, 99432, 99433, 99435, 99436, 99440 Preventive Medicine 94772, 96110, 99386, 99387, 99396, 99397 Obstetric Care Vaccines 59020, 59025, 59050, 59300, 59400, 59409, 59410, 59412, 59414, 59425, 59426, 59430, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620, 59622, 59812, 59820, 59821, 59830, 76801, 76802, 76805, 76810, 76811, 76815, 76816, 76818, 76819, 76825, 76826, 76827, 76828 99204 + modifier "TH" (for initial antepartum care visit)** 99213 + modifier "TH" (for two to three antepartum care visits, after initial visit)** 90701, 90702, 90704, 90705, 90706, 90707, 90708, 90712, 90713, 90718, 90744 *Providers should not submit claims with HPSA modifier “AQ” and modifier “TJ” (Program group, child and/or adolescent) for procedure codes 99201-99215 and 99281-99285. Providers should use only a HPSA modifier, when applicable. Wisconsin Medicaid will determine the recipient’s age and determine the proper HPSA reimbursement for these procedure codes. **Providers are required to use modifier "TH" (Obstetrical treatment/services, prenatal or postpartum) with procedure codes 99204 and 99213 only when those codes are used to indicate the first three antepartum care visits. Providers are required to use both the "TH" modifier and HPSA modifier “AQ” when these prenatal services are HPSA eligible for appropriate reimbursement. Continued Physician Services Handbook — Medicine and Surgery December 2005 149 Appendix
Page 1 and 2:
Physician Services Medicine and Sur
Page 3 and 4:
T Table of Contents Preface .......
Page 5 and 6:
Telemedicine ......................
Page 7:
Health Professional Shortage Areas
Page 10 and 11:
Legal Framework The following laws
Page 12 and 13:
General Information Treatment (EPSD
Page 14 and 15:
General Information Category III Co
Page 16 and 17:
General Information collecting the
Page 18 and 19:
General Information • The current
Page 20 and 21:
Evaluation and Management reimburse
Page 22 and 23:
Evaluation and Management in an out
Page 24 and 25:
Evaluation and Management 22 Wiscon
Page 26 and 27:
Medicine Services System [HCPCS] co
Page 28 and 29:
Medicine Services In cases where mo
Page 30 and 31:
Medicine Services documentation in
Page 32 and 33:
Medicine Services Providers of ment
Page 34 and 35:
Medicine Services Substance Abuse S
Page 36 and 37:
Surgery Services Appendix 10 of thi
Page 38 and 39:
Surgery Services Cataract Surgery W
Page 40 and 41:
Surgery Services and the insertion
Page 42 and 43:
Surgery Services Note: A telephone
Page 44 and 45:
Surgery Services • Sterilization.
Page 46 and 47:
Surgery Services live with her sinc
Page 48 and 49:
Surgery Services by a multi-discipl
Page 50 and 51:
Prescription Requirements Prescribe
Page 52 and 53:
Prescription Requirements Approval
Page 54 and 55:
Prescription Requirements prescribe
Page 56 and 57:
Prescription Requirements 54 Wiscon
Page 58 and 59:
Claims Submission adjustment reques
Page 60 and 61:
Claims Submission 58 Wisconsin Medi
Page 62 and 63:
Reimbursement • Confirming or rev
Page 64 and 65:
Reimbursement about whether a speci
Page 66 and 67:
Reimbursement 64 Wisconsin Medicaid
Page 68 and 69:
Appendix 66 Wisconsin Medicaid and
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
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Appendix Appendix 4 (Continued) If
Page 82 and 83:
Appendix Appendix 4 (Continued) Ele
Page 84 and 85:
Appendix Appendix 4 (Continued) Ele
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Appendix (This page was intentional
Page 98 and 99:
ABORTION CERTIFICATION STATEMENTS P
Page 100 and 101: Appendix (This page was intentional
Page 102 and 103: STERILIZATION INFORMED CONSENT FORM
Page 104 and 105: DEPARTMENT OF HEALTH AND FAMILY SER
Page 114 and 115: Appendix Appendix 15 (Continued) Pe
Page 116 and 117: Appendix Category Musculoskeletal S
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
Page 124 and 125: Appendix 122 Wisconsin Medicaid and
Page 132 and 133: Appendix PRIOR AUTHORIZATION / PHYS
Page 136 and 137: PRIOR AUTHORIZATION / PHYSICIAN ATT
Page 140 and 141: PRIOR AUTHORIZATION / “J” CODE
Page 144 and 145: PRIOR AUTHORIZATION / “J” CODE
Page 148 and 149: PRIOR AUTHORIZATION / PHYSICIAN OTO
Page 152 and 153: Appendix Health Professional Shorta
Page 154 and 155: Appendix HPSA Name County ZIP Codes
Page 158 and 159: Appendix Appendix 26 (Continued) ma
Page 160 and 161: Appendix The following table lists
Page 172 and 173: DECLARATION OF SUPERVISION FOR NONB
Page 176 and 177: Appendix HCPCS Code* Drug Name Diag
Page 178: Index Organ Transplants, 44 Provide
show all

Medicine and Surgery Section - Wisconsin.gov

Create successful ePaper yourself

Delete template?

Save as template?