Medicine and Surgery Section - Wisconsin.gov

Surgery Services
live with her since birth. She must send
this statement to her county/tribal eligibility
worker in the envelope provided and is
required to tell her eligibility worker that
she has a new baby with a temporary
Medicaid identification number.
• Once the mother notifies her worker and
her child has received a Social Security
number, a permanent Medicaid number is
assigned to the child.
Providers with questions regarding newborn
eligibility may contact Provider Services.
Newborn Screenings
Wisconsin Medicaid covers the cost of prepaid
filter paper cards in addition to the laboratory
handling fee for newborn screenings provided
outside a hospital setting. Refer to the
Laboratory and Radiology section of this
handbook for more information.
Organ Transplants
Wisconsin Medicaid reimburses physicians and
transplant centers (hospitals) for organ
transplants when they are:
• Medically necessary.
• Prior authorized (with the exception of
kidney and cornea transplants which do
not require PA).
• Performed in an approved United
Network for Organ Sharing (UNOS)
transplant center. Refer to the Data page
of the Organ Procurement and
Transplantation Network Web site at
www.optn.org/ for UNOS-approved
organ transplant centers.
Prior to making a referral to an approved
transplant center, Wisconsin Medicaid
recommends that physicians verify that the
transplant center currently accepts Wisconsin
Medicaid recipient referrals and Medicaid
reimbursement for the proposed transplant.
Prior Authorization Requirements
For all transplants requiring PA, the transplant
center in which the transplant will occur is
required to request PA, not the physician. The
transplant center and the physician are
encouraged to jointly complete the PA request.
In cases of multiple organ transplants where
no single CPT code describes the procedure
performed, indicate each individual procedure
code, if available, on the PA request.
Physicians should not indicate the PA number
on the claim for the transplant surgery.
Sterilizations
General Requirements
A sterilization is any surgical procedure
performed with the primary purpose of
rendering an individual permanently incapable
of reproducing. The procedure may be
performed in an “open” or laparoscopic
manner. This does not include procedures that,
while they may result in sterility, have a
different purpose such as surgical removal of a
cancerous uterus or cancerous testicles.
Providers should refer to the physician services
maximum allowable fee schedule for allowable
sterilization procedure codes.
Medicaid reimbursement for sterilizations is
dependent on providers fulfilling all federal and
state requirements and satisfactory completion
of a Sterilization Informed Consent form, HCF
1164. There are no exceptions. Federal and
state regulations require the following:
• The recipient is not an institutionalized
individual.
• The recipient is at least 21 years old on the
date the informed written consent is
obtained.
• The recipient gives voluntary informed
written consent for sterilization.
• The recipient is not a mentally incompetent
individual. Wisconsin Medicaid defines a
“mentally incompetent” individual as a
44 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005
For all transplants
requiring PA, the
transplant center
in which the
transplant will
occur is required
to request PA, not
the physician.