Medicine and Surgery Section - Wisconsin.gov

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Reimbursement • Confirming or revising diagnoses. • Determining the course of treatment to be followed. • Making frequent review of the recipient’s progress. The notes must indicate that the supervising physician personally reviewed the recipient’s medical history, performed a physical and/or psychiatric examination, confirmed or revised the diagnosis, and discharged the recipient. Residents Wisconsin Medicaid reimburses residents for physician services when: • The resident is fully licensed to practice medicine and has obtained a Medicaid provider number. • The service can be separately identified from those services that are required as part of the training program. • The resident is operating independently and not under the direct supervision of a physician. • The service is provided in a clinic, an outpatient hospital, or emergency department setting. The reimbursement for residents is identical to other licensed physicians. Physician Assistants Wisconsin Medicaid generally reimburses physician assistants 90 percent of the payment allowed for the physician who would have otherwise performed the service. Physician assistants are paid 100 percent of the physician’s maximum fee for HealthCheck screens, injections, immunizations, lab handling fees, and select diagnostic procedures. Nurse Practitioners Nurse practitioners receive the same reimbursement as physicians for services. Ancillary Providers Wisconsin Medicaid covers counseling services (e.g., weight management, diabetic, smoking cessation, and prenatal services), coordination of care services, and delegated medical acts (e.g., giving injections or immunizations, checking medications, changing dressings) provided by ancillary providers if all of the following are true: • The services are provided under the direct, immediate, on-site supervision of a physician. • The services are pursuant to the physician’s plan of care. • The supervising physician has not also provided Medicaid reimbursable services during the same office or outpatient evaluation and management (E&M) visit. Examples of ancillary providers include non- Medicaid certifiable health care professionals such as staff nurses, dietician counselors, nutritionists, health educators, genetic counselors, and some nurse practitioners. (Nurse practitioners, nurse midwives, and anesthetists who are Medicaid certified should refer to their service-specific Medicaid publications for billing information.) “On-site” means that the supervising physician is in the same building in which services are being provided and is immediately available for consultation or, in the case of emergencies, for direct intervention. The physician is not required to be in the same room as the ancillary provider, unless dictated by medical necessity and good medical practice. Since ancillary providers are not Medicaideligible providers, claims for these services must be submitted under the supervising physician’s Medicaid provider number using the lowest appropriate level office or outpatient visit procedure code or other appropriate Current Procedural Terminology (CPT) code for the service performed. These services are not to be billed in addition to or combined with the physician service if the physician sees the patient during the same visit. 60 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005 Wisconsin Medicaid generally reimburses physician assistants 90 percent of the payment allowed for the physician who would have otherwise performed the service.
Surgical procedures performed by the same physician, for the same recipient, on the same DOS, must be submitted on the same claim form. Surgical Procedures Surgical procedures performed by the same physician, for the same recipient, on the same DOS must be submitted on the same claim form. Surgeries that are billed on separate claim forms are denied. Reimbursement for most surgical procedures includes reimbursement for preoperative and postoperative care days. Preoperative and postoperative surgical care includes the preoperative evaluation or consultation, postsurgical E&M services (i.e., hospital visits, office visits), suture, and cast removal. Although E&M services pertaining to the surgery for DOS during the preoperative and postoperative care days are not covered, an E&M service may be reimbursed if it was provided in response to a different diagnosis. Co-surgeons Wisconsin Medicaid reimburses each surgeon at 100 percent of Wisconsin Medicaid’s usual surgeon rate for the specific procedure he or she has performed. Attach supporting clinical documentation (such as an operative report) clearly marked “co-surgeon” to each surgeon’s paper claim to demonstrate medical necessity. Surgical Assistance Wisconsin Medicaid reimburses for surgical assistance at 20 percent of the maximum allowable fee for the surgical procedure. To receive reimbursement for surgical assistance, indicate the surgery procedure code with modifier “80” (assistant surgeon) on the claim. Wisconsin Medicaid reimburses surgical assistance only for those surgeries that are listed in the physician fee schedule with modifier “80.” Physician assistants performing surgical assistance receive 90 percent of the maximum allowable fee for the surgery (with modifier “80”). Bilateral Surgeries Bilateral surgical procedures are paid at 150 percent of the maximum allowable fee for the single service. Indicate modifier “50” (bilateral procedure) and a quantity of 1.0 on the claim. Multiple Surgeries Multiple surgical procedures performed by the same physician for the same recipient during the same surgical session are reimbursed at 100 percent of the maximum allowable fee for the primary procedure, 50 percent for the secondary procedure, 25 percent for the tertiary procedure, and 13 percent for all subsequent procedures. The Medicaid-allowed surgery with the greatest usual and customary charge on the claim is reimbursed as the primary surgical procedure, the next highest is the secondary surgical procedure, etc. Wisconsin Medicaid permits full maximum allowable payments for surgeries that are performed on the same DOS but at different surgical sessions. For example, if a provider performs a sterilization on the same DOS as a delivery, the provider may be reimbursed the full maximum allowable fee for both procedures if performed at different times (and if all of the billing requirements were met for the sterilization). To obtain full reimbursement, submit a claim for all the surgeries performed on the same DOS that are being billed for the recipient. Then submit an Adjustment/Reconsideration Request for the allowed claim with additional supporting documentation clarifying that the surgeries were performed in separate surgical sessions. Refer to the Medicaid Web site for a copy of the Adjustment/Reconsideration Request. Note: Most diagnostic and certain vascular injection and radiological procedures are not subject to the multiple surgery reimbursement limits. Call Provider Services at (800) 947-9627 or (608) 221-9883 for more information Physician Services Handbook — Medicine and Surgery December 2005 61 Reimbursement
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Physician Services Medicine and Sur
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Health Professional Shortage Areas
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Legal Framework The following laws
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Appendix SECTION II — RECIPIENT I
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Appendix PRIOR AUTHORIZATION / PHYS
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PRIOR AUTHORIZATION / “J” CODE
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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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