Medicine and Surgery Section - Wisconsin.gov

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Office and Other Outpatient Visits........................................................................................... 19 Established Patient ........................................................................................................... 19 New Patient ..................................................................................................................... 19 Office Visit Daily Limit........................................................................................................ 19 Office Located in Hospital.................................................................................................. 19 Office Visits and Counseling ............................................................................................... 20 Physician Counseling Visits Under s. 253.10, Wis. Stats. ..................................................... 20 Preventive Medicine Services .................................................................................................. 20 Annual Physicals ............................................................................................................... 20 HealthCheck Screenings .................................................................................................... 20 Tobacco Cessation Services.................................................................................................... 21 Drugs for Tobacco Cessation ............................................................................................ 21 Medicine Services ........................................................................................................................ 23 Allergy Tests ......................................................................................................................... 23 Audiometry ........................................................................................................................... 23 Biofeedback .......................................................................................................................... 23 Chemotherapy ...................................................................................................................... 23 Anti-Emetic Drugs ............................................................................................................ 24 Clozapine Management .......................................................................................................... 24 Evoked Potentials .................................................................................................................. 24 End-Stage Renal Disease Services........................................................................................... 24 Dialysis Treatment Provided Outside the Recipient’s Home .................................................. 24 Home Dialysis Recipients ................................................................................................... 25 Home Dialysis Recipients Who are Hospitalized ................................................................... 25 Fluoride — Topical Applications ................................................................................................ 25 Coverage......................................................................................................................... 25 Submitting Claims ............................................................................................................. 25 Training Materials ............................................................................................................. 26 Hospital Admissions ............................................................................................................... 26 Certificate of Need Requirements for Recipients Admitted to an Institution for Mental Disease ........................................................................................................... 26 Immunizations ...................................................................................................................... 26 Vaccines for Children Program ........................................................................................... 27 Vaccines for Recipients Older than Age 19 ......................................................................... 27 Synagis ® Coverage ........................................................................................................... 27 Provider-Administered Drugs ................................................................................................... 28 Diagnosis Restrictions ....................................................................................................... 28 Prior Authorization Requirements ....................................................................................... 28 Unclassified Drugs ............................................................................................................ 28 Reimbursement ............................................................................................................... 28 Laboratory Test Preparation and Handling Fees ....................................................................... 29 Additional Limitations ......................................................................................................... 29 Mental Health Services ........................................................................................................... 29 Psychiatric Medication Checks ................................................................................................. 29 Screenings ............................................................................................................................ 30 Screening Procedures Coverage ........................................................................................ 30 Diagnostic Procedures ...................................................................................................... 30 Service-Specific Information .............................................................................................. 30 Substance Abuse Services...................................................................................................... 32
Telemedicine ......................................................................................................................... 32 Weight Management Services ................................................................................................ 32 Surgery Services ......................................................................................................................... 33 Abortions .............................................................................................................................. 33 Coverage Policy ............................................................................................................... 33 Covered Services ............................................................................................................. 33 Coverage of Mifeprex ....................................................................................................... 33 Physician Counseling Visits Under s. 253.10, Wis. Stats. ..................................................... 34 Services Incidental to a Noncovered Abortion ..................................................................... 34 Anesthesia by Surgeon .......................................................................................................... 34 Bariatric Surgery .................................................................................................................... 34 Breast Reconstruction ............................................................................................................ 35 Cataract Surgery ................................................................................................................... 36 Surgical Care Only ............................................................................................................ 36 Postoperative Management .............................................................................................. 36 Preoperative Management ................................................................................................ 37 Cochlear Implants ................................................................................................................. 37 Contraceptive Implants .......................................................................................................... 37 Informed Consent Procedure ............................................................................................ 37 Informed Consent Documentation..................................................................................... 38 Co-surgeons/Assistant Surgeons............................................................................................. 38 Dilation and Curettage............................................................................................................ 38 Foot Care ............................................................................................................................. 38 Unna Boots ..................................................................................................................... 38 Hysterectomies ..................................................................................................................... 38 Intrauterine Devices .............................................................................................................. 39 Obstetric Services .................................................................................................................. 39 Separate Obstetric Care Components ................................................................................ 39 Global Obstetric Care ........................................................................................................ 41 Separately Covered Pregnancy-Related Services ................................................................ 41 Unusual Pregnancies ........................................................................................................ 42 Complications of Pregnancy .............................................................................................. 42 Unrelated Conditions ......................................................................................................... 42 Health Professional Shortage Area Incentive Reimbursement .............................................. 42 Other Insurance/Private Pay Prior to Wisconsin Medicaid Eligibility ........................................ 42 Fee-for-Service Recipients Subsequently Enrolled in a Medicaid HMO or SSI MCO ................. 42 Newborn Reporting ................................................................................................................ 43 Responsibility for Reporting ............................................................................................... 43 Newborn Report Submission .............................................................................................. 43 Newborn Report Procedures ............................................................................................. 43 Newborn Screenings .............................................................................................................. 44 Organ Transplants ................................................................................................................. 44 Prior Authorization Requirements ....................................................................................... 44 Sterilizations .......................................................................................................................... 44 General Requirements ...................................................................................................... 44 Sterilization Consent Form ................................................................................................. 45 Temporomandibular Joint Surgery ........................................................................................... 45 Prior Authorization Requirements ....................................................................................... 45 Vagal Nerve Stimulators ......................................................................................................... 46
Page 1 and 2: Physician Services Medicine and Sur
Page 3: T Table of Contents Preface .......
Page 7: Health Professional Shortage Areas
Page 10 and 11: Legal Framework The following laws
Page 12 and 13: General Information Treatment (EPSD
Page 14 and 15: General Information Category III Co
Page 16 and 17: General Information collecting the
Page 18 and 19: General Information • The current
Page 20 and 21: Evaluation and Management reimburse
Page 22 and 23: Evaluation and Management in an out
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
Page 30 and 31: Medicine Services documentation in
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
Page 50 and 51: Prescription Requirements Prescribe
Page 52 and 53: Prescription Requirements Approval
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Prescription Requirements prescribe
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Prescription Requirements 54 Wiscon
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Claims Submission adjustment reques
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Claims Submission 58 Wisconsin Medi
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Reimbursement • Confirming or rev
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Reimbursement about whether a speci
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Reimbursement 64 Wisconsin Medicaid
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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 Appendix 4 (Continued) If
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Appendix Appendix 4 (Continued) Ele
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Appendix Appendix 4 (Continued) Ele
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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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