Medicine and Surgery Section - Wisconsin.gov

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Appendix HCPCS Code* Drug Name Diagnosis Code Disease Description J1830 Interferon Beta 1B (Betaseron) 340 Multiple Sclerosis J2505 Pegfilgrastim (Neulasta) 2880 Agranulocytosis/Neutropenia J2820 Sargramostim (Leukine) 205 Myeloid leukemia J7505 Muromonab CD 3 (Orthoclone OKT-3) 9968 Organ transplant failure or rejection J9212 Interferon Alfacon 1 (Infergen) 07054 Chronic hepatitis C without mention of hepatic coma J9213 Interferon Alfa 2A (Roferon-A) J9214 Interferon Alfa 2B (Intron A) 07054 Chronic hepatitis C without mention of hepatic coma 1729 Malignant melanoma 1760-1769 Kaposi’s sarcoma 2024 Hairy cell leukemia 2028 Non-hodgkin’s lymphoma 2030 Multiple myeloma 2051 Chronic myelocytic leukemia 2337 Bladder carcinoma 2339 Renal cell carcinoma 07054 Chronic hepatitis C without mention of hepatic coma 07811 Condyloma acuminatum 1729 Malignant melanoma 1760-1769 Kaposi’s sarcoma 2024 Hairy cell leukemia 2028 Non-hodgkin’s lymphoma 2030 Multiple myeloma 2337 Bladder carcinoma 2339 Renal cell carcinoma J9215 Interferon Alfa N3 (Alferon N) 07811 Condyloma acuminatum J9216 Q0136 and Q4055 Interferon Gamma 1B 2881 Chronic granulomatous disease (Actimmune) 75652 Osteopetrosis 042, 07953 140-20491, 230- Anemia from Acquired Immune Deficiency Syndrome (AIDS) 2386, 2388- Non-myeloid malignancies or multiple myeloma Epoetin (Epogen and Procrit) 2399, 2733 20610 Chronic myelomonocytic leukemia 2387, 2849, 2850 Myelodysplastic syndrome 28521 Anemia in end-stage renal disease 585 Chronic renal failure Q3026 Interferon Beta 1A in Albumin (Rebif) 340 Multiple Sclerosis *HCPCS = Healthcare Common Procedure Coding System 174 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005
Abortions, 33, 55, 93 Ancillary Providers, 60 Audiometry, 23 Bariatric Surgery, 34 Biofeedback, 23 Breast Reconstruction, 35 CMS 1500 general information, 55 instructions, 77 samples, 83, 85, 87, 89 Cataract Surgery, 36 Certification, 9 Chemotherapy, 23 Claims, 55 Clozapine Management, 24 Cochlear Implants, 36 Contraceptive Implants, 36 Copayment, 13 Co-surgeons, 38 Counseling abortion, 34 contraceptive implants, 37 office visits, 20 psychotherapy, see psychotherapy Covered Services, 11 Dietary Counselor, 60 Dilation and Curettage, 37 Documentation Requirements, 14 End-Stage Renal Disease Services, 24 Index Evaluation and Management Services, 17 Evoked Potentials, 24 Experimental Services, 15 Fluoride — Topical Applications, 25 Foot Care, 37 Genetic Counselor, 60 HealthCheck certification, 9 enhanced reimbursement, 62 general information, 20 “Other Services,” 21 Health Personnel Shortage Area (HPSA), 62, 149 Hospital Admissions, 26 Hysterectomies, 13, 38, 55, 105 Immunizations, 26 Intrauterine Devices, 38 Laboratory Test Preparation and Handling Fees, 29 Medicine Services, 23 Mental Health Services, 29 Non-U.S. Citizens, 13 Laboratory Preparation and Handling Fees, 29 Maximum Allowable Fees, 59 Maximum Daily Reimbursement, 59 McKesson ClaimCheck, 56, 57 Mental Health Services, 29 Newborn Reporting, 43, 165 Nutritionist, 60 Obstetric Services, 39 Physician Services Handbook — Medicine and Surgery December 2005 175 Index
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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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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 Appendix 4 (Continued) If
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Appendix Appendix 4 (Continued) Ele
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Appendix Appendix 4 (Continued) Ele
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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 Appendix 15 (Continued) Pe
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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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Page 132 and 133: Appendix PRIOR AUTHORIZATION / PHYS
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Page 154 and 155: Appendix HPSA Name County ZIP Codes
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Page 160 and 161: Appendix The following table lists
Page 172 and 173: DECLARATION OF SUPERVISION FOR NONB
Page 178: Index Organ Transplants, 44 Provide
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