Medicine and Surgery Section - Wisconsin.gov

Medicine Services
System [HCPCS] codes J9000-J9999).
Reimbursement for these procedure codes
includes the cost of the drug and the charge for
administering the drug. (If the physician’s
office does not supply the drug, use procedure
code 90782 or 90784 on claims for the
injection. Use the appropriate procedure code
for the infusion when performed by the
physician.)
When chemotherapy for a malignancy is
provided in an inpatient hospital, outpatient
hospital, or nursing home setting, physician
services providers may receive reimbursement
for the E&M visit only.
Anti-Emetic Drugs
Wisconsin Medicaid covers physicianadministered
anti-emetic drugs for recipients
receiving chemotherapy. The appropriate
HCPCS “Q” code should be indicated when
submitting a claim for a physician-administered
oral anti-emetic drug for a Medicaid recipient
receiving chemotherapy. Before submitting a
claim, providers are responsible for verifying
that a pharmacy is not already billing for an
anti-emetic drug given to a recipient for the
same DOS.
Clozapine Management
Clozapine management is a specialized care
management service that may be required to
ensure the safety of recipients who are
receiving this psychoactive medication.
Wisconsin Medicaid reimburses clozapine
separately for outpatient and nursing home
residents. Clozapine management is
reimbursable only for outpatient services.
Refer to Appendix 26 of this section for more
information about Medicaid coverage of
clozapine management.
Evoked Potentials
Only audiologists and physicians with
specialties of neurology, otolaryngology,
ophthalmology, physical medicine and
rehabilitation, anesthesiology, and psychiatry
can be reimbursed for evoked potential testing.
Wisconsin Medicaid covers the following
evoked potential tests:
• Brain stem evoked response recording.
• Visual evoked potential study.
• Somatosensory testing.
• Intraoperative neurophysiological testing
reimbursed by the hour.
These evoked potential tests are allowed once
per day per recipient. When two or more types
of evoked potential tests are performed on the
same DOS (e.g., brain stem and visual),
reimbursement is 100 percent of the Medicaid
maximum allowable fee for the first test, with a
lesser amount for the second and subsequent
tests.
End-Stage Renal Disease
Services
Physician services providers should submit
claims with HCPCS procedure codes G0308-
G0327 for professional end-stage renal disease
(ESRD)-related services. These services may
be reimbursed once per calendar month per
recipient. Recipient copayments are deducted
for these services as appropriate.
Dialysis Treatment Provided
Outside the Recipient’s Home
Providers should submit claims with procedure
codes G0308-G0319 for ESRD recipients who
are receiving dialysis treatment somewhere
other than in their home. Providers should
indicate the appropriate procedure code based
on the age of the recipient and the number of
face-to-face visits per month. The visits may
occur in the physician’s office, an outpatient
hospital or other outpatient setting, or the
recipient’s home, as well as the dialysis facility.
If the visits occur in multiple locations,
providers should indicate on claims the place of
service code where most of the visits
occurred.
24 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005
When two or more
types of evoked
potential tests are
performed on the
same DOS (e.g.,
brain stem and
visual),
reimbursement is
100 percent of the
Medicaid
maximum
allowable fee for
the first test, with
a lesser amount
for the second and
subsequent tests.