Medicine and Surgery Section - Wisconsin.gov

Health Professional Shortage Areas ......................................................................................... 62
Modifiers .......................................................................................................................... 63
Antepartum Care Visits Performed in a Health Professional Shortage Area ........................... 63
Pediatric Services Performed in a Health Professional Shortage Area .................................... 63
HealthCheck Services Not Eligible for Health Professional Shortage Area Incentive Payment .. 63
Appendix .................................................................................................................................... 65
1. Allowable Procedure Codes and Modifiers for Physician Evaluation and Management,
Medicine, and Surgical Services ............................................................................................. 67
2. Allowable Modifiers for Physician Evaluation and Management, Medicine, and Surgery
Services ............................................................................................................................... 73
3. Allowable Place of Service Codes for Physician Evaluation and Management, Medicine, and
Surgery Services .................................................................................................................. 75
4. CMS 1500 Claim Form Instructions for Physician Services ....................................................... 77
5. Sample CMS 1500 Claim Form — Physician Medical Services (Three Evaluation and
Management Visits with Pediatric Modifier) ............................................................................. 83
6. Sample CMS 1500 Claim Form — Physician Obstetrical Services (Antepartum Care in a
Health Professional Shortage Area) ........................................................................................ 85
7. Sample CMS 1500 Claim Form — Physician Surgical Services (Bilateral Surgery) ........................ 87
8. Sample CMS 1500 Claim Form — End-Stage Renal Disease Services (Recipient Other
Than Home Dialysis) ............................................................................................................ 89
9. Antepartum Care Claims Submission Guide ............................................................................ 91
10. Abortion Certification Statements (for photocopying) .............................................................. 93
11. Sterilization Informed Consent Instructions and Sample .......................................................... 97
12. Sterilization Informed Consent (for photocopying) ................................................................ 103
13. Acknowledgment of Receipt of Hysterectomy Information (for photocopying) ........................ 105
14. Breast Pump Order (for photocopying) ................................................................................ 109
15. Physician Services Requiring Prior Authorization ..................................................................... 111
16. Prior Authorization Request Form (PA/RF) Completion Instructions for Physician Services ........ 119
17. Sample Prior Authorization Request Form (PA/RF) ................................................................ 123
18. Prior Authorization / Physician Attachment (PA/PA) Completion Instructions ........................... 125
19. Sample Prior Authorization / Physician Attachment (PA/PA) ................................................... 129
20. Prior Authorization / Physician Attachment (PA/PA) (for photocopying) .................................. 131
21. Prior Authorization / “J” Code Attachment (PA/JCA) Completion Instructions .......................... 135
22. Prior Authorization / “J” Code Attachment (for photocopying) ............................................... 139
23. Prior Authorization / Physician Otological Report (PA/POR) Completion Instructions ................. 143
24. Prior Authorization / Physician Otological Report (PA/POR) (for photocopying) ........................ 147
25. Health Professional Shortage Area-Eligible Procedure Codes and ZIP Codes ............................ 149
26. Clozapine Management ...................................................................................................... 155
27. Allowable Temporomandibular Joint Surgery and Anesthesia Procedure Codes and
Temporomandibular Joint Evaluation Programs ..................................................................... 159
28. Certification of Need for Specialized Medical Vehicle Transportation ........................................ 161
29. Wisconsin Medicaid Newborn Report (for photocopying) ........................................................ 165
30. Declaration of Supervision for Nonbilling Providers Instructions ............................................... 167
31. Declaration of Supervision for Nonbilling Providers (for photocopying) ..................................... 171
32. Diagnosis-Restricted Provider-Administered Drugs ................................................................. 173
Index ....................................................................................................................................... 175