Medicine and Surgery Section - Wisconsin.gov

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Evaluation and Management reimbursement for services in excess of four hours is requested must be included. Refer to the Medicaid Web site for a copy of the Adjustment/Reconsideration Request. Wisconsin Medicaid only reimburses prolonged care services (CPT procedure codes 99354- 99357 and 99360) if there is face-to-face contact between the provider and the recipient. Prolonged care services without face-to-face contact (CPT codes 99358 and 99359) are not covered by Wisconsin Medicaid. Ambulance Services Critical care services provided by physicians in an air or ground ambulance are reimbursed under either critical care or prolonged care procedure codes. Claims for services provided in an ambulance must be submitted on a paper claim with a copy of the physician’s clinical record attached. Wisconsin Medicaid does not reimburse physicians for supervising from the home base of a hospital’s emergency transportation unit or for supervising in the ambulance. Emergency Department Services When a specific surgical procedure (e.g., fracture care) is provided as an emergency service, an E&M procedure code is ordinarily not reimbursed for the same recipient on the same DOS. The reimbursement for the surgical procedure includes payment for E&M services as well. Separate reimbursement may be available for emergency E&M services and emergency services that are of unusually high complexity. Providers in these situations may submit an Adjustment/Reconsideration Request for the allowed surgical claim. Attach a copy of the emergency department visit report to the completed Adjustment/Reconsideration Request. The situations and reason for requesting additional/separate reimbursement should be explained in the “Other/comments” portion of the Adjustment Information section of the form. Evaluation and Management Services Provided with Surgical Procedures If a provider performs an office or a hospital visit and a surgical procedure on the same DOS for the same recipient, the provider will receive reimbursement for the surgical procedure only. However, if the surgery is a minor surgery (as determined by Wisconsin Medicaid), the provider may submit an adjustment request for the allowed surgery claim to request additional reimbursement for the E&M service. Refer to the Claims Information section of the All-Provider Handbook for more information. If the E&M service was unrelated to the surgery, the E&M service may be reimbursed if it is billed under a different diagnosis code than the diagnosis code for the surgery. Family Planning Services Family planning services are defined as services performed to enable individuals of childbearing age to determine the number and spacing of their children. This includes minors who are sexually active. To enable the state to obtain Federal Financial Participation funding for family planning services, the accurate completion of the following elements on the claim is essential: • Diagnosis code from V25 series. • Appropriate diagnosis code reference to procedure code. • Family Planning Indicator “F.” Hospital Services Wisconsin Medicaid ordinarily reimburses physicians for a moderate-level hospital admission procedure code if the physician has provided an E&M service or consultation at 18 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005 Wisconsin Medicaid only reimburses prolonged care services (CPT procedure codes 99354-99357 and 99360) if there is face-to-face contact between the provider and the recipient.
Wisconsin Medicaid reimburses one routine nursing home visit per calendar month per recipient. the highest level of service in the seven days prior to the hospital admission date. Nursing Home Visits Wisconsin Medicaid reimburses one routine nursing home visit per calendar month per recipient. If a physician visits a nursing home recipient more frequently, medical records must document the medical necessity of the additional visits. When submitting a claim for a nursing home visit, use the most appropriate CPT procedure code based on the level of service provided. Observation Care Observation care procedure codes 99217- 99220 or 99234-99236 are covered by Wisconsin Medicaid. Observation care includes all E&M services performed by the admitting physician on the date a recipient is admitted into observation care. This includes related services provided at other sites and all E&M services provided in conjunction with the admission into observation status. Only the admitting physician may submit a claim for observation care. Other physicians are required to use another appropriate E&M outpatient or consultation procedure code. When submitting claims for observation care, use the appropriate CPT procedure code. Only one observation care procedure code may be reimbursed per recipient, per DOS, per provider. Observation care codes are not reimbursed for recipients admitted into hospital inpatient care on the same DOS. Only place of service (POS) codes “22” (outpatient hospital) and “23” (emergency room — hospital) may be indicated on claims for observation care. Office and Other Outpatient Visits Established Patient An established patient is one who has, within the past three years, received professional services from the same physician or another physician of the same specialty who belongs to the same group practice. New Patient A new patient is defined as a patient who is new to the provider and whose medical and administrative records need to be established. A new patient has not received professional services from either the physician or group practice within the past three years. Office Visit Daily Limit Wisconsin Medicaid reimburses only one office visit per recipient, per provider, per DOS. However, an established patient office visit may be reimbursed in addition to a preventive medicine office visit by the same provider on the same DOS if an abnormality is encountered or a pre-existing problem is addressed in the process of performing the preventive medicine visit. The abnormality/ problem must be a significant, medically necessary, separately identifiable E&M service that is documented in the recipient’s medical record. In addition, the abnormality/problem must be significant enough to require additional work to perform the key component of a problem-oriented E&M service. Separate reimbursement for more than one E&M visit on the same DOS as a preventive visit are subject to post-pay review and may be recouped if documentation is inadequate to justify separate payment. Office Located in Hospital Physicians may submit claims for services performed in a physician’s office that is located Physician Services Handbook — Medicine and Surgery December 2005 19 Evaluation and Management
Page 1 and 2: Physician Services Medicine and Sur
Page 3 and 4: T Table of Contents Preface .......
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Page 7: Health Professional Shortage Areas
Page 10 and 11: Legal Framework The following laws
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Page 16 and 17: General Information collecting the
Page 18 and 19: General Information • The current
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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
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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
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Page 52 and 53: Prescription Requirements Approval
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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
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Page 68 and 69: 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 74 Wisconsin Medicaid and
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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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Appendix PRIOR AUTHORIZATION / PHYS
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PRIOR AUTHORIZATION / PHYSICIAN ATT
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PRIOR AUTHORIZATION / “J” CODE
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PRIOR AUTHORIZATION / “J” CODE
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PRIOR AUTHORIZATION / PHYSICIAN OTO
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Appendix Health Professional Shorta
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Appendix HPSA Name County ZIP Codes
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Appendix Appendix 26 (Continued) ma
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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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