Medicine and Surgery Section - Wisconsin.gov

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Surgery Services • Sterilization. (Refer to “Sterilizations” for sterilization limitations.) • Surgical complications of pregnancy (e.g., incompetent cervix, hernia repair, ovarian cyst, Bartholin cyst, ruptured uterus, or appendicitis). Unusual Pregnancies Providers treating recipients whose pregnancies require more than the typical number of antepartum or postpartum visits or result in complications during delivery may seek additional reimbursement by submitting an Adjustment/Reconsideration Request, HCF 13046, for the allowed claim. Include a copy of the medical record and/or delivery report specifying the medical reasons for the extraordinary number of antepartum or postpartum visits. Wisconsin Medicaid will review the materials and determine the appropriate level of reimbursement. The Adjustment/Reconsideration Request may be downloaded and printed from the Forms page of the Medicaid Web site. Complications of Pregnancy Complications of pregnancy or delivery, such as excessive bleeding, pregnancy-induced hypertension, toxemia, hyperemesis, premature (not-artificial) rupture of membranes, and other complications during the postpartum period may all be reported and reimbursed separately from obstetrical care. The nature of these complications should be fully documented in the recipient’s medical record. Unrelated Conditions Any E&M services performed that are related to the pregnancy are included in reimbursement for obstetrical care. However, conditions unrelated to the pregnancy may be separately reimbursed by Wisconsin Medicaid. These may include: • Chronic hypertension. • Diabetes. • Management of cardiac, neurological, or pulmonary problems. • Other conditions (e.g., urinary tract infections) with a diagnosis other than complication of pregnancy. Health Professional Shortage Area Incentive Reimbursement Many OB procedure codes are eligible for the Health Professional Shortage Area (HPSA)enhanced reimbursement. Submit claims with HPSA modifier “AQ” to receive a 50 percent bonus incentive. Refer to the Reimbursement chapter of this section for more information about HPSA-enhanced reimbursement. Other Insurance/Private Pay Prior to Wisconsin Medicaid Eligibility Wisconsin Medicaid OB payments apply only to services provided while the person is eligible as a Medicaid recipient. Services provided prior to Wisconsin Medicaid eligibility are not included in the number of antepartum visits, the delivery, or postpartum care. Fee-for-Service Recipients Subsequently Enrolled in a Medicaid HMO or SSI MCO Wisconsin Medicaid will reimburse the equivalent of one global OB fee per recipient, per delivery, per single provider or provider group, whether the provider receives the reimbursement through fee-for-service Medicaid or through a Medicaid HMO or SSI MCO. A recipient who is initially eligible for fee-forservice Medicaid may enroll in a Medicaid MCO during her pregnancy and receive care from the same provider or clinic. In this case, the provider may be paid a global fee by the MCO after the provider receives payment from fee-for-service Medicaid for the antepartum care. If this is the case, the provider is required to submit an adjustment request to have the fee-for-service Medicaid payment recouped. 42 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005 Many OB procedure codes are eligible for the Health Professional Shortage Area (HPSA)-enhanced reimbursement.
Physicians, nurse practitioners, and nurse midwives should submit a Newborn Report only if the mother is not enrolled in a Medicaid HMO and the birth occurs outside a hospital setting. If the provider does not submit an adjustment request in this situation, Wisconsin Medicaid will recoup the fee-for-service payment(s) through audit. If the recipient receives less than global OB care while enrolled in the Medicaid MCO, Wisconsin Medicaid reimburses her provider no more than the global maximum allowable fee or the sum of the individual components for services. Wisconsin Medicaid will, on audit, recoup any amount paid under fee-for-service that is more than the global fee or the combined maximum allowable fee for the services if billed separately. Newborn Reporting Providers are required to indicate a newborn’s Medicaid identification number on claims. Providers may report babies born to Medicaid recipients by submitting a Newborn Report form, HCF 1165, to Wisconsin Medicaid. Establishing a newborn’s Medicaid eligibility results in better health outcomes and fewer delays in provider reimbursement. The Newborn Report form is located in Appendix 29 of this section and may also be downloaded and printed from the Medicaid Web site. Providers without Internet access should call Provider Services at (800) 947-9627 or (608) 221-9883 to request a paper copy of the form. Questions about the form may also be directed to Provider Services. Responsibility for Reporting Hospitals, Medicaid HMOs, physicians, nurse practitioners, and nurse midwives may report babies born to Medicaid recipients by submitting a Wisconsin Medicaid Newborn Report to Wisconsin Medicaid. Providers may develop and use their own form that contains the same information as the Newborn Report. Physicians, nurse practitioners, and nurse midwives should submit a Newborn Report only if the mother is not enrolled in a Medicaid HMO and the birth occurs outside a hospital setting. Otherwise, the hospital or Medicaid HMO completes the form. If a mother is enrolled in a Medicaid HMO but has her baby outside the HMO network, the HMO is responsible for reporting the birth to Wisconsin Medicaid. The Newborn Report should be submitted to Wisconsin Medicaid even in instances in which the baby is born alive but does not survive. If the mother was not covered by Wisconsin Medicaid when the baby was born, she can apply for Medicaid retroactively. If her dates of eligibility include the date of the baby’s birth, her baby can also receive retroactive and continuous eligibility for the first year of life. Newborn Report Submission Providers have the option of sending newborn reports in a summary format on a weekly basis to Wisconsin Medicaid or individual reports for each newborn. However, the summary report must contain all the information provided in the Newborn Report. If possible, the Newborn Report should be submitted to Wisconsin Medicaid with the child’s given name (first and last name), rather than “baby boy” or “baby girl” as the first name. Newborn Report Procedures Once the completed Newborn Report is submitted to Wisconsin Medicaid, the following procedures take place: • A pseudo (temporary) Medicaid identification number is assigned to the newborn, regardless of whether or not the newborn is named (if Medicaid eligibility is not yet on file). • A Medicaid Forward card is created for the child and sent to the mother as soon as the child’s eligibility is put on file. • Wisconsin Medicaid sends a letter to the mother, notifying her of the child’s eligibility. The letter also contains a statement that the mother is required to sign, stating that the baby has continued to Physician Services Handbook — Medicine and Surgery December 2005 43 Surgery Services
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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
Page 20 and 21: Evaluation and Management reimburse
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Appendix 92 Wisconsin Medicaid and
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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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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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