Medicine and Surgery Section - Wisconsin.gov

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Appendix 88 Wisconsin Medicaid and BadgerCare dhfs.wisconsin.gov/medicaid/ December 2005
P Recipient, Im A. 02 10 96 X 609 Willow Anytown WI 55555 XXX XXX-XXXX 585 OI - P 1234567890 08 01 04 08 04 04 12 G0325 1 XXX XX 4.0 12345678 08 08 04 08 10 04 12 G0325 1 XXX XX 3.0 12345678 MM/DD/YY Appendix 8 Sample CMS 1500 Claim Form — End-Stage Renal Disease Services (Recipient Other Than Home Dialysis) 1234JED XXX XX XX XX XX XX I.M. Billing 1 W. Williams Anytown, WI 55555 87654321 Physician Services Handbook — Medicine and Surgery December 2005 89 Appendix
Page 1 and 2:
Physician Services Medicine and Sur
Page 3 and 4:
T Table of Contents Preface .......
Page 5 and 6:
Telemedicine ......................
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
Page 54 and 55: Prescription Requirements prescribe
Page 56 and 57: Prescription Requirements 54 Wiscon
Page 58 and 59: Claims Submission adjustment reques
Page 60 and 61: Claims Submission 58 Wisconsin Medi
Page 62 and 63: Reimbursement • Confirming or rev
Page 64 and 65: Reimbursement about whether a speci
Page 66 and 67: Reimbursement 64 Wisconsin Medicaid
Page 68 and 69: Appendix 66 Wisconsin Medicaid and
Page 70 and 71: Appendix Surgery Services Appendix
Page 72 and 73: Appendix Medicine Services (Continu
Page 74 and 75: Appendix Other Services Appendix 1
Page 80 and 81: Appendix Appendix 4 (Continued) If
Page 82 and 83: Appendix Appendix 4 (Continued) Ele
Page 84 and 85: Appendix Appendix 4 (Continued) Ele
Page 96 and 97: Appendix (This page was intentional
Page 98 and 99: ABORTION CERTIFICATION STATEMENTS P
Page 102 and 103: STERILIZATION INFORMED CONSENT FORM
Page 104 and 105: DEPARTMENT OF HEALTH AND FAMILY SER
Page 114 and 115: Appendix Appendix 15 (Continued) Pe
Page 116 and 117: Appendix Category Musculoskeletal S
Page 118 and 119: Appendix Category Musculoskeletal S
Page 120 and 121: Appendix Category Female Genital Sy
Page 122 and 123: Appendix SECTION II — RECIPIENT I
Page 132 and 133: Appendix PRIOR AUTHORIZATION / PHYS
Page 136 and 137: PRIOR AUTHORIZATION / PHYSICIAN ATT
Page 140 and 141:
PRIOR AUTHORIZATION / “J” CODE
Page 142 and 143:
Appendix (This page was intentional
Page 144 and 145:
PRIOR AUTHORIZATION / “J” CODE
Page 146 and 147:
Page 148 and 149:
PRIOR AUTHORIZATION / PHYSICIAN OTO
Page 150 and 151:
DEPARTMENT OF HEALTH AND FAMILY SER
Page 152 and 153:
Appendix Health Professional Shorta
Page 154 and 155:
Appendix HPSA Name County ZIP Codes
Page 156 and 157:
Appendix 154 Wisconsin Medicaid and
Page 158 and 159:
Appendix Appendix 26 (Continued) ma
Page 160 and 161:
Appendix The following table lists
Page 162 and 163:
Appendix 160 Wisconsin Medicaid and
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
DECLARATION OF SUPERVISION FOR NONB
Page 174 and 175:
Page 176 and 177:
Appendix HCPCS Code* Drug Name Diag
Page 178:
Index Organ Transplants, 44 Provide
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