Medicine and Surgery Section - Wisconsin.gov

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Claims Submission adjustment request include, but are not limited to, the following: • Critical care and prolonged services lasting longer than six hours. • Emergency room services with unique circumstances or unusually high complexity. • Obstetrical services with an unusually high number of antepartum or postpartum care visits or complications. Unlisted Procedures Claims for services identified by unlisted (nonspecific) procedure codes must be submitted on paper because a national standard for electronic claim attachments has not been established at this time. To receive reimbursement for a service identified by an unlisted procedure code, a description of the service must be indicated in Element 19 of the paper claim. If Element 19 does not provide enough space for the description, or if a provider is billing multiple unlisted procedure codes, documentation may be attached to the claim. In this instance, the provider should indicate “see attachment” in Element 19. The description in Element 19 or the documentation attached to the claim must be sufficient to allow Wisconsin Medicaid to determine the nature and scope of the procedure and whether the procedure was medically necessary as defined in Wisconsin Administrative Code. ClaimCheck Review Wisconsin Medicaid monitors claims for compliance with Medicaid reimbursement policy using an automated procedure coding review software known as McKesson ClaimCheck ® . This software reviews claims submitted to Wisconsin Medicaid for billing inconsistencies and errors with respect to Current Procedural Terminology (CPT) codes. ClaimCheck review may affect claims in one of the following ways: 1. The claim is unchanged by the review. 2. The procedure codes are rebundled into one or more appropriate codes. 3. One or more of the codes is denied as incidental/integral or mutually exclusive. ClaimCheck monitors the following Medicaid policy areas: 1. Unbundling (Code Splitting) Unbundling occurs when two or more CPT codes are used to describe a procedure that may be better described by a single, more comprehensive code. ClaimCheck considers the single, most appropriate code for reimbursement when unbundling is detected. If a provider submits a claim for certain procedure codes separately, ClaimCheck rebundles them into the single, most appropriate panel. For example, if a provider submits a claim with two procedure codes for layer closure of wounds, 12.6 cm to 20.0 cm and 20.1 cm to 30.0 cm (procedure codes 12035 and 12036), ClaimCheck rebundles them to layer closure of wounds over 30.0 cm (procedure code 12037). ClaimCheck totals billed amounts for individual procedures. For example, if a provider submits a claim for three procedures at $20, $30, and $25, ClaimCheck rebundles them into a single procedure code, adds the three amounts, and calculates the billed amount for that rebundled code at $75. However, Wisconsin Medicaid reimburses the provider either the lesser of the billed amount or the maximum allowable fee for that procedure code. 2. Incidental/Integral Procedures Incidental procedures are those procedures performed at the same time as a more complex primary procedure. They 56 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005 Claims for services identified by unlisted (nonspecific) procedure codes must be submitted on paper because a national standard for electronic claim attachments has not been established at this time.
Integral procedures are those procedures performed as part of a more complex primary procedure. require few additional physician resources and are generally not considered necessary to the performance of the primary procedure. For example, the removal of an asymptomatic appendix is considered an incidental procedure when done during a hysterectomy surgery. Integral procedures are those procedures performed as part of a more complex primary procedure. For example, when a recipient undergoes a transurethral incision of the prostate (procedure code 52000), the cystourethroscopy is considered integral to the performance of the prostate procedure. When a procedure is either incidental or integral to a major procedure, ClaimCheck considers only the primary procedure for reimbursement. 3. Mutually Exclusive Procedures Mutually exclusive procedures are procedures that would not be performed on a single recipient during the same operative session or that use different codes to describe the same type of procedure. For example, a vaginal hysterectomy (procedure code 58260) and a total abdominal hysterectomy (procedure code 58150) are mutually exclusive — either one or the other procedure is performed, but not both. When two or more procedures are mutually exclusive, Wisconsin Medicaid reimburses the procedure code with the highest provider-billed amount. If circumstances warrant an exception, submit an Adjustment/Reconsideration Request, HCF 13046, with supporting documentation and the words “medical consultant review requested” written on the request. The completion instructions and Adjustment/Reconsideration Request are located in the Claims Information section of the All-Provider Handbook and may also be downloaded and printed from the Medicaid Web site. Why Was Payment for a Service Denied by ClaimCheck? Providers should take the following steps if they are uncertain about why particular services on a claim were denied: 1. Review Medicaid remittance information for the specific reason for the denial. 2. Review the claim submitted to ensure all information is accurate and complete. 3. Consult current CPT and Healthcare Common Procedure Coding System publications to make sure proper coding instructions were followed. 4. Consult this section and other current Wisconsin Medicaid publications to make sure current policy and billing instructions were followed. 5. Call Provider Services at (800) 947-9627 or (608) 221-9883 for further information or explanation. 6. If circumstances warrant an exception, submit an Adjustment Reconsideration/ Request with supporting documentation and the words “medical consultant review requested” written on the form. Physician Services Handbook — Medicine and Surgery December 2005 57 Claims Submission
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Appendix SECTION II — RECIPIENT I
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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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