Medicine and Surgery Section - Wisconsin.gov

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General Information • The current judgment of experts in the applicable medical specialty area. • The judgment of a committee formed by the External Review Organization at the request of Wisconsin Medicaid. Specialized Medical Vehicle Services Wisconsin Medicaid covers specialized medical vehicle (SMV) services if the transportation is to and from a facility where the recipient receives Medicaid-covered services and the recipient meets the eligibility requirements. To be eligible for SMV services, a recipient must be indefinitely disabled, legally blind, or temporarily disabled and must have a medical condition that contraindicates safe travel by common carrier such as bus, taxi, or private vehicle. If a recipient meets the eligibility requirements, a physician, physician assistant, nurse practitioner, or nurse midwife should complete a Certification of Need for Specialized Medical Vehicle Transportation form, HCF 1197. The completion instructions and Certification of Need for Specialized Medical Vehicle Transportation form are located in Appendix 28 of this section for photocopying and may also be downloaded and printed from the Medicaid Web site. If the recipient does not meet the criteria for SMV services, the medical provider should not complete the form. Instead, the provider should refer the recipient to the Medicaid transportation coordinator in his or her county/ tribal social or human services agency. Inconvenience or lack of timely transportation are not valid justifications for the use of SMV transportation. The presence of a disability does not by itself justify SMV transportation. The medical provider gives a copy of the completed form to the recipient who then gives the form to the SMV provider. The medical provider does not need to keep a copy of the completed form on file, but he or she is required to document the medical condition necessitating SMV transportation in the recipient’s medical record. Physicians are required to complete a new Certification of Need (CON) form upon expiration. For recipients who are indefinitely disabled, the CON is valid for 365 days from the date the medical provider signed the form. For recipients who are temporarily disabled, the CON is valid for the period indicated on the form, which must not exceed 90 days from the date the medical provider signed the form. Medical providers must not complete the forms retroactively for SMV providers or recipients. Providers may not charge recipients for completing the Certification of Need for Specialized Medical Vehicle Transportation form. Wisconsin Medicaid will reimburse providers at the lowest level E&M CPT procedure code if the recipient is in the office when the form is completed and no other medical service is provided. Refer to the Prescription Requirements chapter of this section for information about prescriptions for SMV trips exceeding oneway upper mileage limits. 16 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005 Providers may not charge recipients for completing the Certification of Need for Specialized Medical Vehicle Transportation form.
Wisconsin Medicaid covers most of the categories of E&M services described in Current Procedural Terminology (CPT). Evaluation and Management Services Evaluation and management (E&M) services include office visits, hospital visits, and consultations. Specific services include examinations, evaluations, treatments, preventive pediatric and adult health supervision, and similar medical services. Wisconsin Medicaid covers most of the categories of E&M services described in Current Procedural Terminology (CPT). Refer to Appendix 1 of this section for Medicaid-covered E&M services. Wisconsin Medicaid does not cover services in the following CPT categories: • Prolonged Physician Services Without Direct Patient Contact. • Case Management Services. • Care Plan Oversight Services. • Counseling and/or Risk Factor Reduction Intervention. • Special E&M Services. Wisconsin Medicaid does not cover services provided in group settings or telephone conversations between the provider and the recipient, except for outpatient mental health and substance abuse services. (Refer to mental health/substance abuse service-specific publications for more information.) Evaluation and management services must be provided to recipients on a one-on-one basis. Concurrent Care Wisconsin Medicaid covers E&M services provided on the same date of service (DOS) by two or more physicians to a recipient during an inpatient hospital or nursing home stay only when medical necessity is documented in the recipient’s medical record. Consultations Evaluation and management consultations (CPT procedure codes 99241-99275) are covered by Wisconsin Medicaid when provided to a recipient at the request of another provider or when medically necessary and appropriate. Consultation procedure codes are not reimbursed when the recipient is an established patient of the provider billing the consultation. If a provider assumes responsibility for management of the recipient, the use of consultation procedure codes is no longer appropriate. Covered Consultations An E&M consultation requires face-to-face contact between the consultant and the recipient. A consultation must always include a written report that becomes a part of the recipient’s permanent medical record. Claims for consultations should include the referring provider’s name and Medicaid provider number. Critical Care and Prolonged Services Wisconsin Medicaid reimburses up to four hours per DOS for critical care (CPT procedure codes 99291-99292) and prolonged services (CPT procedure codes 99354-99357 and 99360). To request reimbursement for time in excess of four hours per DOS, providers should submit an Adjustment/Reconsideration Request, HCF 13046, for an allowed claim. Supporting clinical documentation (e.g., a history and physical exam report or a medical progress note) that identifies why Physician Services Handbook — Medicine and Surgery December 2005 17 Evaluation and Management
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Appendix 66 Wisconsin Medicaid and
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Appendix Surgery Services Appendix
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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 Category Musculoskeletal S
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Appendix Health Professional Shorta
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Appendix HPSA Name County ZIP Codes
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Appendix The following table lists
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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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Medicine and Surgery Section - Wisconsin.gov

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