Medicine and Surgery Section - Wisconsin.gov

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Surgery Services Appendix 10 of this section for photocopying and may also be downloaded and printed from the Medicaid Web site. Note: Wisconsin Medicaid denies claims for Mifeprex reimbursement when billed with a National Drug Code. Physician Counseling Visits Under s. 253.10, Wis. Stats. Section 253.10, Wis. Stats., provides that a woman’s consent to an abortion is not considered informed consent unless at least 24 hours prior to an abortion a physician has, in person, orally provided the woman with certain information specified in the statute. Pursuant to this statute, the Department of Health and Family Services has issued preprinted material summarizing the statutory requirements and a patient consent form. Copies of these materials may be obtained by writing to the following address: Administrator Division of Public Health PO Box 2659 Madison WI 53701-2659 Wisconsin Medicaid will cover an office visit during which a physician provides the information required by this statute. Services Incidental to a Noncovered Abortion Services incidental to a noncovered abortion are not covered by Wisconsin Medicaid. Such services include, but are not limited to, any of the following services when directly related to the performance of a noncovered abortion: • Anesthesia services. • Laboratory testing and interpretation. • Recovery room services. • Transportation. • Routine follow-up visits. • Ultrasound services. Anesthesia by Surgeon Reimbursement for anesthesia provided by the surgeon (e.g., local infiltration, digital block, conscious sedation, topical anesthesia, regional anesthesia, and general anesthesia) is included in the Medicaid reimbursement for the surgical or diagnostic procedure(s) performed and is not separately reimbursable. However, if the anesthesia is the primary procedure performed, for diagnosis or treatment, it is separately reimbursable. For example, if an intercostal nerve block is done for diagnosis and treatment of post-therapeutic neuralgia, and an epidural steroid injection procedure is also done, the anesthetic procedure is separately reimbursable. Refer to the Anesthesia section of this handbook for more information. Bariatric Surgery All bariatric surgery procedures require PA. The approval criteria for PA requests for Medicaid-covered bariatric surgery procedures include all of the following: • The recipient must have one of the following: A body mass index (BMI) of 40 or greater, or A BMI of between 35 and 39 with documented high-risk, comorbid medical conditions that have not responded to medical management and are a threat to life (e.g., clinically significant obstructive sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy, coronary heart disease, medically refractory hypertension, or severe diabetes mellitus), and • The recipient must have attempted weight loss in the past without successful longterm weight reduction. These attempts may include, but are not limited to, diet restrictions/supplements, behavior modification, physician-supervised weight 34 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005 All bariatric surgery procedures require PA.
Breast reconstruction requires PA; however, PA is waived for breast reconstruction when performed following a mastectomy for breast cancer. loss plans, physical activity programs, commercial or professional programs, or pharmacological therapy. • The prior authorization (PA) request must include clinically documented evidence of all of the following: A minimum of six months of demonstrated adherence by the recipient to a physician-supervised weight management program with at least three consecutive months of participation in this program prior to the date of surgery in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the recipient’s ability to comply with postoperative medical care and dietary restrictions. Supporting documentation must include a physician’s assessment of the recipient’s participation and progress throughout the course of the program. A physician’s summary letter is not sufficient supporting clinical documentation. Agreement by the recipient to attend a medically supervised postoperative weight management program for a minimum of six months for the purpose of ongoing dietary, physical activity, behavioral/psychological, and medical education and monitoring. • The recipient must receive a preoperative evaluation by an experienced and knowledgeable multi-disciplinary bariatric treatment team composed of health care providers with medical, nutritional, and psychological experience. This evaluation must include all of the following: A complete history and physical examination, specifically evaluating for obesity-related comorbidities that would require preoperative management. Evaluation for any correctable endocrinopathy that might contribute to obesity. Dietary assessment and counseling. Psychological/psychiatric evaluation and clearance to determine the stability of the recipient in terms of tolerating the operative procedure and postoperative sequelae, as well as the likelihood of the recipient participating in an ongoing weight management program following surgery. Recipients receiving active treatment for a psychiatric disorder should receive evaluation by their treatment provider prior to bariatric surgery and be cleared for bariatric surgery. • The recipient must be 18 years of age or older and have completed growth. All of the following must be included in the PA request: • A completed Prior Authorization Request Form (PA/RF), HCF 11018. • A completed Prior Authorization/Physician Attachment (PA/PA), HCF 11016. • Clinical documentation supporting the criteria. The following procedures are considered investigational, inadequately studied, or unsafe and therefore are not covered by Wisconsin Medicaid: • Gastric balloon. • Biliopancreatic bypass. • Loop gastric bypass. Breast Reconstruction Breast reconstruction requires PA; however, PA is waived for breast reconstruction when performed following a mastectomy for breast cancer. (Breast reconstruction is identified by Current Procedural Terminology [CPT] codes 19316-19325, 19340-19350, 19357- 19369, 19380-19396.) This is pursuant to the federal Women’s Health and Cancer Rights Act of 1998. Claims for breast reconstruction must include an ICD-9-CM diagnosis code for breast cancer (174.0-174.9, 175.0-175.9, 233.0, 238.3, 239.3) in order for the PA requirement to be waived by Wisconsin Medicaid. Physician Services Handbook — Medicine and Surgery December 2005 35 Surgery Services
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Appendix 84 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 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 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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