Wisconsin Medicaid Podiatry Services Handbook · The Division of Health Care Financing (DHCF) is pleased to provide you with a copy of the new Podiatry Services Handbook. All policies

Podiatry ServicesHandbook

Podiatry ServicesHandbook

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

DIVISION OF HEALTH CARE FINANCING

1 WEST WILSON STREETP O BOX 309

MADISON WI 53701-0309

James E. DoyleGovernor Telephone: 608-266-8922

State of Wisconsin FAX: 608-266-1096Helene Nelson TTY: 608-261-7798Secretary Department of Health and Family Services www.dhfs.state.wi.us

Wisconsin.gov

M E M O R A N D U M

DATE: February 24, 2003

TO: Podiatrists, Managed Care Organizations

FROM: Peggy B. Handrich, AdministratorDivision of Health Care Financing

SUBJECT: New Podiatry Services Handbook

The Division of Health Care Financing (DHCF) is pleased to provide you with a copy of the newPodiatry Services Handbook.

All policies included in the handbook are effective for dates of service on and after May 1, 2003.Please utilize your current handbook, Part V, the Podiatry Handbook, until that date.

The Podiatry Services Handbook incorporates current Medicaid podiatry policy information intoa single reference source. The handbook replaces all prior podiatry services publicationsincluding Part V, the Podiatry Handbook, dated January 1992.

This handbook does not replace the All-Provider Handbook and all-provider Wisconsin Medicaidand BadgerCare Updates, the Wisconsin Administrative Code, or Wisconsin Statutes.Subsequent changes to podiatry services policies will be published first in Wisconsin Medicaidand BadgerCare Updates and later in the Podiatry Services Handbook revisions.

Additional Copies of Publications

All Wisconsin Medicaid and BadgerCare Updates and the Podiatry Services Handbook can bedownloaded from the Medicaid Web site at www.dhfs.state.wi.us/medicaid/.

We would like to thank everyone who reviewed the handbook and provided comments.


IImportant Telephone NumbersWisconsin Medicaid�s Eligibility Verification System (EVS) is available through the following resources to verify checkwriteinformation, claim status, prior authorization status, provider certification, and/or recipient eligibility:

ServiceInformation

Available Telephone Number Hours

Automated VoiceResponse (AVR)System(Computerized voiceresponse to providerinquiries.)

Checkwrite InformationClaim StatusPrior AuthorizationStatusRecipient Eligibility*

(800) 947-3544(608) 221-4247

(Madison area)

24 hours a day/7 days a week

Personal ComputerSoftwareandMagnetic StripeCard Readers

Recipient Eligibility* Refer to ProviderResources section ofthe All-ProviderHandbook for a list ofcommercial eligibilityverification vendors.

24 hours a day/7 days a week

Provider Services(Correspondentsassist withquestions.)

Checkwrite InformationClaim StatusPrior AuthorizationStatusProvider CertificationRecipient Eligibility*

(800) 947-9627(608) 221-9883

Policy/Billing and Eligibility:8:30 a.m. - 4:30 p.m. (M, W-F)9:30 a.m. - 4:30 p.m. (T)Pharmacy:8:30 a.m. - 6:00 p.m. (M, W-F)9:30 a.m. - 6:00 p.m. (T)

Direct InformationAccess Line withUpdates forProviders(Dial-Up)(Softwarecommunicationspackage andmodem.)

Checkwrite InformationClaim StatusPrior AuthorizationStatusRecipient Eligibility*

Call (608) 221-4746for more information.

7:00 a.m. - 6:00 p.m. (M-F)

Recipient Services(Recipients orpersons calling onbehalf of recipientsonly.)

Recipient EligibilityMedicaid-CertifiedProvidersGeneral MedicaidInformation

(800) 362-3002(608) 221-5720

7:00 a.m. - 5:00 p.m. (M-F)

*Please use the information exactly as it appears on the recipient�s identification card or the EVS to complete the patientinformation section on claims and other documentation.

Recipient eligibility information available through the EVS includes:

� Dates of eligibility.� Medicaid managed care program name and telephone number.� Privately purchased managed care or other commercial health insurance coverage.� Medicare coverage.� Lock-In Program status.� Limited benefit information.


TTable of Contents

Preface ............................................................................................................................ 3

General Information ......................................................................................................... 5

Provider Information .................................................................................................... 5Scope of Service...................................................................................................... 5Provider Eligibility and Certification ............................................................................ 5

Recipient Information ................................................................................................... 5Recipient Eligibility .................................................................................................. 5Copayment............................................................................................................. 5

Services........................................................................................................................... 7

Covered Podiatry Services ............................................................................................. 7Medical Necessity .................................................................................................... 7

Evaluation and Management Services .............................................................................. 8Established Patient .................................................................................................. 8New Patient ............................................................................................................ 8Office Located in Hospital ......................................................................................... 8Office Visits and Counseling ...................................................................................... 8Limitations Applicable to Evaluation and Management Procedure Codes.......................... 9Ancillary Providers .................................................................................................. 9

Surgical Procedures ...................................................................................................... 9Limitations Applicable to Surgical Procedures .............................................................. 9Routine Foot Care .................................................................................................. 10

Limitations Applicable to Routine Foot Care .......................................................... 10Mycotic Conditions and Mycotic Nails ......................................................................... 10

Limitations Applicable to Mycotic Conditions and Mycotic Nails................................. 10Casting/Strapping/Taping ........................................................................................ 10

Physical Medicine ........................................................................................................ 11Laboratory ................................................................................................................. 11

Clinical Certification for Laboratory Services ............................................................... 11CLIA Enrollment ............................................................................................... 11Further CLIA Information ................................................................................... 11

Complete Procedure vs. Professional and Technical Components for Laboratory Services.. 11Radiology................................................................................................................... 12

Complete Procedure vs. Professional and Technical Components for Radiology Services... 12Drugs/Injections ......................................................................................................... 12

Covered Procedure Codes ....................................................................................... 12Reimbursement ..................................................................................................... 12Vitamin B-12 ......................................................................................................... 13Corticosteroid Injections .......................................................................................... 13Other Injections ..................................................................................................... 13

PHC 1417


Prescriptions for Drugs ................................................................................................ 13General Prescription Requirements ........................................................................... 13Prescribing Brand-Name Legend Drugs ..................................................................... 14Prescribing Drugs Manufactured by Companies Who Have Not Signed the Rebate

Agreement ....................................................................................................... 14Over-the-Counter Drugs .......................................................................................... 15Compound Drugs .................................................................................................. 15Drug Utilization Review System ................................................................................ 15

Noncovered Services.................................................................................................... 15

Preparing Claims.............................................................................................................17

Claims Submission Process ........................................................................................... 17Electronic Claims Submission ................................................................................... 17Paper Claims Submission ........................................................................................ 17Where to Send Your Claims ..................................................................................... 17Claims Submission Deadline .................................................................................... 17

Reimbursement .......................................................................................................... 17Documentation Requirements .................................................................................. 18

Claim Components ...................................................................................................... 18Procedure Codes .................................................................................................... 18Diagnosis Codes .................................................................................................... 18Billed Amounts ...................................................................................................... 18

Specific Instructions for Podiatry Services ....................................................................... 18Routine Foot Care .................................................................................................. 18Bilateral Surgeries .................................................................................................. 19Laboratory Tests..................................................................................................... 19

Laboratory Tests and Preparation Fees .................................................................. 19McKesson ClaimCheck® Monitors Medicaid Policy ............................................................. 19

Appendix ....................................................................................................................... 21

1. Allowable Podiatry Services CPT and HCPCS Procedure Codes .......................................... 232. Allowable Podiatry Services Local Codes......................................................................... 253. Required Routine Foot Care Diagnosis Codes .................................................................. 274. Allowable Surgical Procedure Codes for Mycotic Conditions............................................... 315. Allowable Diagnosis Codes for Mycotic Conditions and Mycotic Nails .................................. 336. Copayment Amounts and Allowable Podiatry Type of Service and Place of Service Codes ..... 357. Completion Instructions for the CMS 1500 Claim Form .................................................... 378. Completed Sample of the CMS 1500 Claim Form ............................................................ 43

Glossary of Common Terms .............................................................................................. 45

Index ............................................................................................................................. 49


Podiatry Services Handbook � May 2003 3

PPrefaceThe Wisconsin Medicaid and BadgerCare PodiatryServices Handbook is issued to podiatrists that areWisconsin Medicaid certified. It contains information thatapplies to fee-for-service Medicaid providers. TheMedicaid information in the handbook applies to bothWisconsin Medicaid and BadgerCare.

Wisconsin Medicaid and BadgerCare are administered bythe Department of Health and Family Services (DHFS).Within the DHFS, the Division of Health Care Financing(DHCF) is directly responsible for managing WisconsinMedicaid and BadgerCare. As of January 2003,BadgerCare extends Medicaid coverage to uninsuredchildren and parents with incomes at or below 185% ofthe federal poverty level and who meet other programrequirements. BadgerCare recipients receive the samehealth benefits as Wisconsin Medicaid recipients and theirhealth care is administered through the same deliverysystem.

Medicaid and BadgerCare recipients enrolled in state-contracted HMOs are entitled to at least the samebenefits as fee-for-service recipients; however, HMOsmay establish their own requirements regarding priorauthorization, billing, etc. If you are an HMO networkprovider, contact your managed care organizationregarding its requirements. Information contained in thisand other Medicaid publications is used by the DHCF toresolve disputes regarding covered benefits that cannotbe handled internally by HMOs under managed carearrangements.

Verifying EligibilityWisconsin Medicaid providers should always verify arecipient�s eligibility before providing services, both todetermine eligibility for the current date and to discoverany limitations to the recipient�s coverage. WisconsinMedicaid�s Eligibility Verification System (EVS) provideseligibility information that providers can access a numberof ways.

Refer to the Important Telephone Numbers page at thebeginning of this handbook for detailed information on themethods of verifying eligibility.

Handbook OrganizationThe Podiatry Services Handbook consists of the followingchapters:

� General Information.� Services.� Preparing Claims.

In addition to the Podiatry Services Handbook, eachMedicaid-certified podiatrist is issued a copy of the All-Provider Handbook. The All-Provider Handbook includesthe following sections:

� Claims Submission.� Coordination of Benefits.� Covered and Noncovered Services.� Prior Authorization.� Provider Certification.� Provider Resources.� Provider Rights and Responsibilities.� Recipient Rights and Responsibilities.

Legal Framework of WisconsinMedicaid and BadgerCareThe following laws and regulations provide the legalframework for Wisconsin Medicaid and BadgerCare:

Federal Law and Regulation� Law: United States Social Security Act; Title XIX (42

US Code ss.1396 and following) and Title XXI.� Regulation: Title 42 CFR Parts 430-498 � Public

Health.

Wisconsin Law and Regulation� Law: Wisconsin Statutes: Sections 49.43-49.499 and

49.665.� Regulation: Wisconsin Administrative Code, Chapters

HFS 101-108.

Handbooks and Wisconsin Medicaid and BadgerCareUpdates further interpret and implement these laws andregulations.


4 Wisconsin Medicaid and BadgerCare � May 2003

Handbooks and Updates, maximum allowable feeschedules, helpful telephone numbers and addresses, andmuch more information about Wisconsin Medicaid andBadgerCare are available at the following Web sites:

www.dhfs.state.wi.us/medicaid/www.dhfs.state.wi.us/badgercare/.

Medicaid Fiscal AgentThe DHFS contracts with a fiscal agent, which iscurrently EDS.



GGeneral Information

Provider Information

Scope of ServiceThe policies in the Podiatry Services Handbookgovern services provided within the scope ofpractice of the profession as defined ins.448.60(4), Wis. Stats.

Provider Eligibility and CertificationTo become a Wisconsin Medicaid-certifiedpodiatrist under HFS 105.265, Wis. Admin.Code, providers must be currently licensed topractice podiatry in Wisconsin, pursuant tos.448.63(1), Wis. Stats., and registered underPod. 4.01, Wis. Admin. Code.

Recipient Information

Recipient EligibilityWisconsin Medicaid providers should verifyrecipient eligibility and identify any limitations tothe recipient�s coverage before providingservices. Refer to the All-Provider Handbookfor detailed information on accessing theEligibility Verification System and eligibility forWisconsin Medicaid. For telephone numbersregarding recipient eligibility, refer to theImportant Telephone Numbers page at thebeginning of this handbook.

CopaymentExcept as noted below, all recipients areresponsible for paying part of the costsinvolved in obtaining podiatry services.

Copayment amounts are determined perprocedure code per date of service as listed inAppendix 6 of this handbook.

There is a $30.00 calendar year limit perrecipient per provider for podiatry servicecopayments. For clinics with a billing providernumber, the limitation is calculated per recipientper billing provider number instead of perrecipient per performing provider number. Forindividual podiatrists billing under their ownprovider number and not under a clinicprovider number, the limitation is per recipientper podiatrist.

Providers are reminded of the followingcopayment exemptions:

� Emergency services.� Services covered by Wisconsin Medicaid

HMOs and provided to HMO enrollees.� Services provided to a pregnant woman if

the services are related to the pregnancy.� Services provided to nursing home

residents.� Services provided to recipients under 18

years of age.

The copayment must be collected from therecipient by the service provider. Applicablecopayment amounts are automaticallydeducted by Wisconsin Medicaid fromallowable payments.

General Inform

ation

TThe policies in the PodiatryServices Handbook governservices provided within thescope of practice of theprofession as defined ins. 448.60(4), Wis. Stats.



Gen

eral

Info

rmat

ion



SServices

Covered Podiatry ServicesCovered podiatry services include thosemedically necessary services for the diagnosisand treatment of the feet and ankles asdescribed in HFS 101-108, Wis. Admin. Code.Foot care is a covered service when therecipient�s condition requires treatment by apodiatrist to ensure the health and safety of therecipient.

Wisconsin Medicaid reimburses podiatrists forprocedures involving the tendons or muscles ofthe lower leg, provided the diagnosis or treatmentrelates to the feet. Claims for proceduresperformed by podiatrists which do not relate tothe care of the foot and ankle are denied.

In accordance with HFS 107.14(b), Wis. Admin.Code, covered podiatry services include thefollowing:

� Evaluation and management services.� Surgical procedures, including:

√ Multiple surgeries.√ Routine foot care.√ Mycotic procedures.√ Casting/strapping/taping.

� Physical medicine.� Laboratory.� Radiology.� Drugs/injections.� Prescriptions for drugs.

Due to overlapping policy and coveragelimitations between these categories of services,it is important to become familiar with all policiespertaining to covered podiatry services. Refer toAppendices 1 and 2 of this handbook for lists ofallowable procedure codes for podiatrists.

Medical NecessityIn accordance with HFS 101.03(96m), Wis.Admin. Code, Wisconsin Medicaid onlyreimburses providers for those services thatare medically necessary, appropriate, and, tothe extent that alternative services areavailable, the most cost-effective.

�Medically necessary� means a medicalassistance service under ch. HFS 107 that is:

(a) Required to prevent, identify or treat arecipient�s illness, injury or disability; and

(b) Meets the following standards:1. Is consistent with the recipient�s

symptoms or with prevention,diagnosis or treatment of therecipient�s illness, injury or disability;

2. Is provided consistent with standardsof acceptable quality of careapplicable to the type of service, thetype of provider and the setting inwhich the service is provided;

3. Is appropriate with regard to generallyaccepted standards of medicalpractice;

4. Is not medically contraindicated withregard to the recipient�s diagnoses, therecipient�s symptoms or othermedically necessary services beingprovided to the recipient;

5. Is of proven medical value orusefulness and, consistent with s. HFS107.035, is not experimental in nature;

6. Is not duplicative with respect to otherservices being provided to therecipient;

7. Is not solely for the convenience ofthe recipient, the recipient�s family ora provider;

Services

IIn accordance with HFS101.03(96m), Wis. Admin.Code, Wisconsin Medicaidonly reimburses providers forthose services that aremedically necessary,appropriate, and, to theextent that alternativeservices are available, themost cost-effective.



8. With respect to prior authorization ofa service and to other prospectivecoverage determinations made by thedepartment, is cost-effectivecompared to an alternative medicallynecessary service which isreasonably accessible to the recipient;and

9. Is the most appropriate supply or levelof service that can safely andeffectively be provided to the recipient.

Evaluation andManagement ServicesEvaluation and management (E&M) servicesinclude office visits, hospital visits, andconsultations. Specific services include:

� Emergency room visits.� Evaluations.� Examinations.� Home visits.� Hospital visits.� Nursing home visits.� Preventive pediatric and adult health

supervision.� Treatments.

Wisconsin Medicaid covers most of thecategories of E&M services described inCurrent Procedural Terminology (CPT).Refer to Appendix 1 of this handbook forE&M procedure codes that WisconsinMedicaid covers.

Podiatrists may perform and be reimbursed byWisconsin Medicaid for certain E&M servicesprovided to new or established patients inorder to evaluate the need for podiatryservices.

Established PatientAn established patient is one who has receivedprofessional services from the podiatrist oranother podiatrist who belongs to the samegroup practice within the past three years.

New PatientA new patient is defined as a patient who isnew to the provider and whose medical andadministrative records need to be established. Anew patient has not received professionalservices from either the podiatrist or podiatrist�sgroup practice within the past three years.

Office Located in HospitalProviders should submit claims for servicesperformed in a podiatrist�s office which islocated in an outpatient hospital facility with aplace of service (POS) code �3� (office).

Office Visits and CounselingWisconsin Medicaid reimburses podiatrists forface-to-face office visits during which thepodiatrist or the podiatrist�s designee counsels arecipient as to available courses of treatment.Submit a claim for office counseling for theappropriate level E&M service (CPTprocedure codes 99201-99215), even ifcounseling was the only service provided duringthe visit. This is true even if some of thepossible courses of treatment discussed, and theone ultimately selected by the recipient, are notreimbursable under Wisconsin Medicaid.

Wisconsin Medicaid denies reimbursement forcounseling services not identified as part ofthese E&M office visit procedure codes.Counseling provided to individuals to promotehealth and prevent illness or injury in theabsence of symptoms or established illness(CPT procedure codes 99401-99404) is notreimbursable by Wisconsin Medicaid.

Wisconsin Medicaid does not cover procedurecodes in the following CPT categories forpodiatrists:

� Care plan oversight services.� Case management services.� Counseling and/or risk factor reduction

intervention.� Prolonged provider service without direct

patient contact.� Special E&M services.

Serv

ices PPodiatrists may perform and

be reimbursed by WisconsinMedicaid for certain E&Mservices provided to new orestablished patients in orderto evaluate the need forpodiatry services.



Limitations Applicable to Evaluationand Management Procedure CodesEvaluation and management procedure codesare separately reimbursable by WisconsinMedicaid when billed in conjunction withphysical medicine, laboratory/radiology, anddrugs/injections. An E&M procedure is notseparately reimbursable when performed onthe same date of service (DOS) as routine footcare, mycotic procedures, surgery, or casting/strapping/taping. New and established E&Mprocedures are also not separately reimbursablefor surgical procedures subject to preoperativeand postoperative care restrictions, asreimbursement for the visit is included in thereimbursement for the surgical procedure.

Note: Wisconsin Medicaid does not recognizethe CPT modifier �25.�

Ancillary ProvidersWisconsin Medicaid covers services providedby dietary counselors, nutritionists, healtheducators, and other ancillary providers only ifthe services are provided under the direct,immediate, on-site supervision of a podiatrist aspart of a podiatry E&M visit. It is notnecessary for the podiatrist to have face-to-face contact with the recipient on every visitwith an ancillary provider, except as dictatedby good medical practice.

�On-site� means that the supervising podiatristis in the same building in which services arebeing provided and is immediately available forconsultation or, in the case of emergencies, fordirect intervention. The podiatrist is notrequired to be in the same room as theancillary provider, unless dictated by medicalnecessity and good medical practice.

Surgical ProceduresAllowable surgeries of the foot and ankle arecovered services when performed by apodiatrist. Additional surgical proceduresperformed on the same foot within 90 days ofthe original surgery are paid at 50%.

Preoperative and postoperative care, officecalls, and dressings are included in thereimbursement for the surgical procedure.

Claims for multiple surgical proceduresperformed for the same recipient on the sameDOS must be submitted on the same claim form.

Podiatrists are reimbursed for multiplesurgeries as follows:

� The first procedure listed on the claim is paidat 100% of the maximum allowable fee.

� The second procedure at 50%.� The third procedure at 25%.� The fourth and subsequent procedures

at 13%.

Refer to Appendix 1 of this handbook for a listof allowable CPT and Healthcare CommonProcedure Coding System (HCPCS) surgicalprocedure codes.

Limitations Applicable to SurgicalProceduresCertain surgical procedures are presumed toinclude a certain amount of preparatory andfollow-up care. For this reason, reimbursementfor up to three preoperative and varyingpostoperative days is included inreimbursement for certain surgical procedures.Preoperative and postoperative surgical careincludes the preoperative evaluation orconsultation, suture and cast removal, andpostsurgical hospital and office visits. Claimsfor services which fall within the range ofestablished pre- and postcare days for theprocedure(s) being performed are deniedunless they indicate a circumstance ordiagnosis code unrelated to the surgicalprocedure. Surgical procedures are notreimbursable when a claim for a new orestablished patient E&M procedure code issubmitted on the same DOS.

Services

PPreoperative andpostoperative surgical careincludes the preoperativeevaluation or consultation,suture and cast removal, andpostsurgical hospital andoffice visits.



Routine Foot CareRoutine foot care is defined as the cleaning,trimming, cutting, and debridement of toenails,corns, and callouses.

To receive routine foot care, the recipient mustbe under the active care of a physician andhave one of the following diagnoses:

� Arteriosclerosis obliterans evidenced byclaudication.

� Blindness.� Cerebral palsy.� Cerebrovascular accident.� Diabetes mellitus.� Guillian-Barre syndrome.� Multiple sclerosis.� Parkinson�s disease.� Peripheral neuropathies involving the feet,

which are associated with one of thefollowing:√ Malnutrition or vitamin deficiency.√ Diabetes mellitus.√ Drugs and toxins.√ Multiple sclerosis.√ Uremia.

� Polio.� Scleroderma.� Spinal cord injuries.

Refer to the Preparing Claims chapter of thishandbook for claims submission procedures forroutine foot care and to Appendix 2 of thishandbook for allowable routine foot careprocedure codes.

Limitations Applicable to Routine Foot CareRoutine foot care is allowable once per 61days per recipient and is only reimbursablewhen provided to a Medicaid recipient withone of the specific diagnosis codes listed inAppendix 3 of this handbook. Claims forroutine foot care must be submitted using the

routine foot care procedure codes listed inAppendix 2 of this handbook, not a CPT code.

Routine foot care procedures are notreimbursable on the same DOS as a new or anestablished patient E&M procedure code. Donot use E&M procedure codes to submitclaims for routine foot care services.

Mycotic Conditions and Mycotic NailsWisconsin Medicaid reimburses podiatrists forprocedures associated with mycotic conditionsand mycotic nails. Refer to Appendices 4 and 5of this handbook for a list of Medicaid-allowable procedure codes and requireddiagnosis codes for mycotic conditions. Claimsfor mycotic procedures which indicate adiagnosis code not listed in Appendix 5 of thishandbook may be monitored on a post-payment basis for appropriateness of care.

Limitations Applicable to Mycotic Conditionsand Mycotic NailsMycotic procedures are allowed a maximumof six times per year. Wisconsin Medicaiddenies claims submitted in excess of this limit.

Casting/Strapping/TapingCasting, strapping, and taping procedures arecovered services when performed by apodiatrist for the treatment of fractures,dislocations, sprains, strains, and open woundsof the ankle, foot, and toes.

Wisconsin Medicaid does not reimburse forcasting procedures that have the same DOS asa surgical procedure when the castingprocedure is related to the surgery. Theseservices are included in the reimbursement forthe surgical procedure.

Refer to Appendix 1 of this handbook forallowable procedure codes for casting,strapping, and taping.

Serv

ices

RRoutine foot care proceduresare not reimbursable on thesame DOS as a new or anestablished patient E&Mprocedure code.



Physical MedicineThe performance of physical medicineprocedures by a podiatrist are limited to thoseprocedures listed in Appendix 1 of thishandbook, as stated in HFS 107.14(2)(d), Wis.Admin. Code.

LaboratoryClaims for laboratory services may besubmitted by a podiatrist when necessary totreat an injury or disease related to the foot orankle. A preparation or handling fee is allowedand may be reimbursed when billed by apodiatrist for a laboratory specimen sent to anoutside laboratory. Refer to the PreparingClaims chapter of this handbook for billingprocedures and limitations for laboratoryhandling fees and to Appendix 1 of this handbookfor allowable laboratory procedure codes.

Clinical Certification for LaboratoryServicesCongress implemented the Clinical LaboratoryImprovement Amendment (CLIA) to improvethe quality and safety of laboratory services.CLIA requires all laboratories and providersperforming tests for health assessment or forthe diagnosis, prevention, or treatment ofdisease or health impairment to comply withspecific federal quality standards.

CLIA EnrollmentThe federal Centers for Medicare andMedicaid Services (CMS) sends CLIAenrollment information to Wisconsin Medicaid.The enrollment information includes CLIAidentification numbers for all current laboratorysites. Wisconsin Medicaid verifies thatlaboratories are CLIA certified before issuing aMedicaid provider billing number.

Further CLIA InformationFor further information about CLIAregulations, the scope of CLIA, CLIAcertification requirements, and how to becomeCLIA certified, refer to the Provider

Certification section of the All-ProviderHandbook which may be downloaded fromWisconsin Medicaid�s Web site atwww.dhfs.state.wi.us/medicaid/.

Complete Procedure vs.Professional and TechnicalComponents for Laboratory ServicesMost laboratory services are performed andreimbursed as a complete procedure (type ofservice [TOS] �5�). Claims for laboratoryprocedures should be submitted as a completeprocedure (TOS �5�) when both the technicaland professional components are performed bya single laboratory.

A written report must be produced andmaintained in the recipient�s medical recordwhen procedure codes with both technical andprofessional components are submitted witheither a TOS �X� or �5.� If no written report iskept in the recipient�s medical record,Wisconsin Medicaid will recoup forprofessional services upon audit.

At times, the technical component may beperformed by the clinic, but the professionalcomponent is performed by an outsidephysician or laboratory. In these situations,each provider submits claims and is reimbursedonly for the service performed, as follows:

� The provider performing the technicalcomponent indicates only the technicalcomponent (TOS �U�).

� The provider performing the professionalcomponent indicates only the professionalcomponent (TOS �X�). Remember thatthe professional component must result ina written report that is kept in therecipient�s medical record.

The complete procedure (TOS �5�) is notreimbursable to either provider in this situation.

The attending physician�s clinical interpretationof laboratory results is not separatelyreimbursed because it is included in WisconsinMedicaid�s reimbursement for the E&Mservice.

Services

AA written report must beproduced and maintained inthe recipient�s medical recordwhen procedure codes withboth technical andprofessional components aresubmitted with either a TOS�X� or �5.�



RadiologyRadiographs of the foot and ankle are coveredpodiatry services. Refer to Appendix 1 of thishandbook for allowable radiology procedurecodes.

Complete Procedure vs.Professional and TechnicalComponents for Radiology ServicesPodiatrists may be reimbursed for a completeprocedure when performing both theprofessional and technical components ofradiologic procedures, or supervising otherswho do so in the office, clinic, or othernonhospital setting (TOS �4,� �6,� or �K,� asappropriate).

A written report regarding the analysis andinterpretation of radiologic test results isrequired for Wisconsin Medicaidreimbursement of the professional componentof radiologic services. This report must be keptas part of the recipient�s medical record. If nowritten report is kept in the recipient�s medicalrecord, Wisconsin Medicaid will recoup forprofessional services upon audit.

If the POS is a hospital setting (inpatient, POS�1,� or outpatient, POS �2�), or if the technicalportion is performed by a portable X-rayprovider, the clinic may be reimbursed for theprofessional component only, but not for thecomplete procedure. The technical componentis reimbursed to the hospital or provider ofportable X-ray services.

Podiatrists who perform only the technicalcomponent of radiologic services arereimbursed by Wisconsin Medicaid for thetechnical component only. The outside providerperforming the professional component of theservice is reimbursed only for the professionalcomponent.

Drugs/InjectionsPodiatrists may dispense drugs or administerinjections for the treatment of diseases or

injuries of the foot and ankle, including mycoticconditions. For further information aboutWisconsin Medicaid�s coverage of drugs andinjections, refer to the Pharmacy Handbook onthe Wisconsin Medicaid Web site atwww.dhfs.state.wi.us/medicaid/.

Covered Procedure CodesWisconsin Medicaid covers the injectable drugprocedure codes listed in the PhysicianServices Maximum Allowable Fee Schedule.Refer to Appendix 1 of this handbook forinjectable drug �J,� �Q,� and �S� procedurecodes, and to Appendix 2 of this handbook forreimbursable local (or �W�) codes. ThePhysician Services Maximum Allowable FeeSchedule is available on the Medicaid Web siteat www.dhfs.state.wi.us/medicaid/. Providersmay also purchase copies of the fee schedulefrom Wisconsin Medicaid. Copies are availableon paper, microfiche, or diskette. Refer to theClaims Submission section of the All-ProviderHandbook for ordering instructions.

ReimbursementWisconsin Medicaid�s reimbursement for theHCPCS �J,� �Q,� and �S� codes, local �W�drug codes, and the unclassified drug codeincludes reimbursement for the administrationof the drug. Therefore, providers should not billan injection administration code (i.e., CPTprocedure codes 90782, 90783, 90784, and90788) concurrently with a drug code orconcurrently with any other injectionadministration code except as noted below.

To be reimbursed for an unclassified drug thatdoes not require prior authorization (PA) or acovered �J,� �Q,� or �S� code that does nothave a maximum allowable fee listed in thePodiatry Services Maximum Allowable FeeSchedule, podiatrists must submit a completedCMS 1500 claim form and attach the followinginformation:

� Name of drug.� National Drug Code (NDC).� Dosage.� Quantity (e.g., vials, milliliters, milligrams).

Serv

ices

WWisconsin Medicaid�sreimbursement for theHCPCS �J,� �Q,� and �S�codes, local �W� drug codes,and the unclassified drugcode includesreimbursement for theadministration of the drug.



Providers may be separately reimbursed for aninjection administration code only when themedication is supplied and independently billedby a pharmacy using an applicable NDC, orwhen the recipient possesses and provides themedication for injection by a provider.

Vitamin B-12Vitamin B-12 injections are covered only forthe following diagnoses:

� Alcohol neuropathies.� Anemia, post-gastrectomy syndrome.� Anemia, megaloblastic.� Anemia, fish tapeworm.� Anemia, pernicious.� Anemia, post-bowel resection.� Anemia, macrocytic.� Cancer of the stomach, liver, intestines,

and colon.� Strictures of the small intestine.� Anastomosis or partial resection of the

small intestine.� Posterolateral sclerosis.� Sprue or other malabsorption states.� Blind loop syndrome.� Crohn�s disease.

Corticosteroid InjectionsCorticosteroid injections are limited to fourinjections per recipient per any rolling 365-dayperiod, unless the recipient has one of thefollowing diagnoses:

� Neoplasms.� Endocrine, nutritional, and metabolic

diseases and immune disorders.� Diseases of blood and blood-forming

organs.� Multiple sclerosis.� Other demyelinating diseases of the

central nervous system.

Services

Other InjectionsEstrogen and estrone injections are limited tofour per recipient per any 365-day period.

Prescriptions for DrugsWisconsin Medicaid covers both legend andcertain over-the-counter (OTC) drugs. (Alegend drug is one whose outside package hasthe legend or phrase �Caution, federal lawprohibits dispensing without a prescription�printed on it.)

Medicaid coverage for some drugs is restrictedby diagnosis code or prior authorization. Drugsthat are identified by the Food and DrugAdministration (FDA) as less-than-effective(LTE) or as identical, related, or similar to LTEdrugs are not covered by Wisconsin Medicaid.Drugs identified on the Wisconsin NegativeFormulary are also not covered.

For further information regarding WisconsinMedicaid coverage of drugs, contactWisconsin Medicaid�s Provider Services at(800) 947-9627 or (608) 221-9883.

General Prescription RequirementsIt is vital that podiatrists provide adequatedocumentation for the pharmacy or otherproviders to fill a prescription for a legend orOTC drug. Except as otherwise provided infederal or state law, a prescription must be inwriting, or given orally and later reduced towriting by the provider filling the prescription.The prescription must include the followinginformation:

� Date of the order.� Name and address of the prescriber.� Name and address of the recipient.� Prescribed drug or item and directions for

use.� Prescriber�s signature and date.

EExcept as otherwise providedin federal or state law, aprescription must be inwriting, or given orally andlater reduced to writing bythe provider filling theprescription.



Serv

ices

For hospital and nursing home recipients,prescriptions must be entered into the medicaland nursing charts, and must include the aboveinformation. Prescription orders are valid forno more than one year from the date of theprescription except for controlled substancesand prescriber-limited refills which are valid forshorter periods of time. Providers mustmaintain the yearly prescription(s) in therecipient�s medical record, otherwiseWisconsin Medicaid will recoup for thesedrugs upon audit.

Prescribing Brand-Name LegendDrugsWisconsin Medicaid reimburses a pharmacyfor a brand-name drug at the same rateallowed for a generic equivalent unless theprescriber certifies that the brand-name drug ismedically necessary and documents the medicalnecessity in the recipient�s medical record.This requirement applies only to legend drugs.

Prescribers must write the phrase �BRANDMEDICALLY NECESSARY� or�MEDICALLY NECESSARY� on theprescription. (Phrases like �NOSUBSTITUTES� or �N.S.� are notacceptable.) This certification must be in theprescriber�s own handwriting directly on theprescription order or on a separate order whichis attached to the original prescription. Typedcertification, signature stamps, or certificationhandwritten by someone other than theprescribing provider does not satisfy thisrequirement.

A letter of certification is acceptable as long asthe notation is handwritten, is for specifieddrugs for an individual recipient, and is valid fornot more than one year. A �blanket�authorization for an individual recipient, drug, orprescriber is not acceptable.

For recipients in nursing homes, prescribercertification that the brand is medicallynecessary must be made on each prescriptionorder written. This certification is valid only forthe length of time that the order is valid.

Updated written certification is required foreach new prescription order written.

While it is the responsibility of pharmacies tohave this documentation before submitting theirclaims to Wisconsin Medicaid, it is theprescriber�s responsibility to provide apharmacy with the required documentation.

The �Brand Medically Necessary� provisionsdescribed for legend drugs do not apply tocovered OTC drugs. Medicaid coverage forOTC drugs is limited to generic drugs exceptfor the OTC product categories of insulin,ophthalmic lubricants, and contraceptivesupplies.

Prescribing Drugs Manufactured byCompanies Who Have Not Signedthe Rebate AgreementDrug manufacturers who choose to participatein state Medicaid programs are required to signa rebate agreement with the federal CMSunder the drug rebate program. By signing therebate agreement, the manufacturer agrees topay Wisconsin Medicaid a rebate equal to apercentage of its �sales� to WisconsinMedicaid.

Wisconsin Medicaid does not cover drugs ofcompanies choosing not to sign the rebateagreement with few exceptions. A Medicaid-certified pharmacy can confirm for prescriberswhether or not a particular drug manufacturerhas signed the agreement. In addition,providers may refer to the Pharmacy DataTables section of the Pharmacy Handbook fora list. Providers may reference the PharmacyHandbook on the Medicaid Web site atwww.dhfs.state.wi.us/medicaid/.

Wisconsin Medicaid recognizes that there area few cases where it is medically necessary toprovide a drug that is produced by amanufacturer who has not signed a rebateagreement. These drugs may be coveredwhen the pharmacy obtains PA.

PProviders must maintain theyearly prescription(s) in therecipient�s medical record,otherwise WisconsinMedicaid will recoup forthese drugs upon audit.



In this situation, the prescriber must provide thefollowing documentation to the pharmacy:

� A statement indicating that no other drugproduced by a manufacturer that signedthe rebate agreement is medicallyappropriate for the recipient.

� A statement indicating that Medicaidreimbursement of the drug would be costeffective for Wisconsin Medicaid.

A recipient request for a particular drug is notconsidered adequate justification for grantingapproval without the prescriber documentingmedical necessity. Refer to the PharmacyHandbook and the All-Provider Handbook forPA information.

Over-the-Counter DrugsWisconsin Medicaid covers limited categoriesof OTC drugs. Wisconsin Medicaid covers thegeneric products of specific OTC drugcategories from manufacturers who havesigned rebate agreements with CMS (asrequired by the Omnibus Budget ReconciliationAct of 1990 [OBRA �90]). All OTC drugsrequire legal prescriptions in order to becovered by Wisconsin Medicaid.

Compound DrugsWisconsin Medicaid covers a particularcompound drug only when the compoundprescription:

� Contains more than one ingredient.� Contains at least one Medicaid-covered

legend drug.� Does not contain any drug listed on the

Medicaid LTE Drug List or any equivalentor similar drug.

� Does not result in drug combinations thatthe FDA considers LTE.

Wisconsin Medicaid does not cover compoundprescriptions intended for therapeutic use if theFDA does not approve the therapeutic use ofthe combination.

Drug Utilization Review SystemThe federal OBRA �90 (42 CFR Parts 456.703-456.705) called for a Drug Utilization Review(DUR) program for all Medicaid outpatientdrugs to improve the quality and cost-effectiveness of recipient care. Medicaid�sprospective DUR system assists pharmacyproviders in screening certain drug categoriesfor clinically important potential drug therapyproblems before the prescription is dispensedto the recipient.

Prescribers may see an increase in the numberof inquiries, such as telephone calls or faxes,related to prescribed drugs from pharmacyproviders.

Noncovered ServicesAccording to HFS 107.14(3), Wis. Admin.Code, the following services are not covered ifperformed by a podiatrist:

1. Procedures which do not relate to thediagnosis or treatment of the ankle or foot.

2. Palliative or maintenance care, except asdefined as covered routine foot care under�Covered Podiatry Services� in thischapter.

3. All orthopedic and orthotic services,except plaster and other material castprocedures and strapping or tape castingfor treating fractures, dislocations, sprains,or open wounds of the ankle, foot, or toes.

4. Orthopedic shoes and supportive devices,such as arch supports, shoe inlays, andpads.

5. Physical medicine exceeding the limitsspecified in HFS 107.14(2)(d), Wis.Admin. Code.

6. Repairs made to orthopedic and orthoticappliances.

7. Dispensing and repairing corrective shoes.8. Services directed toward the care and

correction of �flat feet.�9. Treatment of subluxation of the foot.10. All other services not specifically identified

as covered in this handbook.

MMedicaid�s prospective DURsystem assists pharmacyproviders in screening certaindrug categories for clinicallyimportant potential drugtherapy problems before theprescription is dispensed tothe recipient.

Services



Serv

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PPreparing Claims

Claims SubmissionProcessAll claims, whether electronic or paper, aresubject to the same Wisconsin Medicaidprocessing and legal requirements.

Electronic Claims SubmissionAll providers, including podiatrists areencouraged to submit claims electronically.Electronic claims submission:

� Reduces processing time.� Eliminates manual handling of claims.� Reduces both claims submission and

processing errors.

Wisconsin Medicaid provides free software forelectronic claims submission. For moreinformation about electronic claims submission:

� Refer to the Claims Submission section ofthe All-Provider Handbook.

� Contact the Electronic Media Claims(EMC) Department at (608) 221-4746.Ask to speak with an EMC coordinator.

Providers who are currently using the freesoftware and have technical questions shouldcontact Wisconsin Medicaid�s softwarecustomer service at (800) 822-8050.

Paper Claims SubmissionProviders submitting paper claims must use theCMS 1500 claim form (dated 12/90). Appendix8 of this handbook contains a completedsample of a CMS 1500 claim form for podiatryservices. Refer to Appendix 7 of this handbookfor CMS 1500 claim form completioninstructions.

Wisconsin Medicaid denies claims for podiatryservices submitted on any other paper claimform than the CMS 1500 claim form.

Wisconsin Medicaid does not provide the CMS1500 claim form. Providers may obtain the formfrom any vendor who supplies federal forms.

Where to Send Your ClaimsMail completed CMS 1500 claim forms to thefollowing address:

Wisconsin MedicaidClaims and Adjustments6406 Bridge RdMadison WI 53784-0002

Claims Submission DeadlineWisconsin Medicaid must receive properlycompleted claims within 365 days from thedate the service was provided. This policyapplies to all initial claims submissions,resubmissions, and adjustment requests.

Exceptions to the 365-day claims submissiondeadline and requirements for submission toLate Billing Appeals can be found in the ClaimsSubmission section of the All-ProviderHandbook. Providers may access the handbookonline at www.dhfs.state.wi.us/medicaid/.

ReimbursementProviders are reimbursed at the lesser of theirusual and customary charge and the maximumallowable fee established by the Department ofHealth and Family Services, less any thirdparty payments.

The maximum allowable fee is the maximumamount that Wisconsin Medicaid will pay aprovider for an allowable procedure code.

To obtain a maximum allowable fee schedule forpodiatry services, providers may:

� Download an electronic version fromWisconsin Medicaid�s Web site atwww.dhfs.state.wi.us/medicaid/.

Preparing ClaimsTThe maximum allowable fee

is the maximum amount thatWisconsin Medicaid will paya provider for an allowableprocedure code.



� Purchase a paper fee schedule by usingthe order form located in the ClaimsSubmission section of the All-ProviderHandbook or by writing to:

Wisconsin MedicaidProvider Maintenance6406 Bridge RdMadison WI 53784-0006

Documentation RequirementsProvider�s should record the followinginformation in the recipient�s record whenproviding a service:

� Recipient�s full name.� Date of service.� Performing provider�s name, title, and

signature.� An accurate, complete, and legible

description of each service provided.� The purpose and need for the service.

Claim Components

Procedure CodesUse the single five-character CurrentProcedural Terminology (CPT) procedurecode, Healthcare Common Procedure CodingSystem (HCPCS) code, or approved localprocedure code that best describes the serviceperformed. Wisconsin Medicaid denies claimsreceived without an appropriate CPT, HCPCS,or local code. Refer to Appendices 1 and 2 ofthis handbook for a list of Medicaid-allowablepodiatry procedure codes.

Do not use multiple procedure codes todescribe a single service.

Diagnosis CodesAll claims submitted for podiatry services mustinclude an appropriate diagnosis code from theInternational Classification of Diseases,Ninth Edition, Clinical Modifications

(ICD-9-CM) coding structure. WisconsinMedicaid denies claims received without anappropriate ICD-9-CM coding structure. Referto Appendices 3 and 5 of this handbook for theappropriate diagnoses for routine foot care andmycotic procedure codes.

Refer to the Provider Resources section of theAll-Provider Handbook for information aboutordering the ICD-9-CM code book.

Billed AmountsProviders are required to bill their usual andcustomary charge for the service performed.The usual and customary charge is theprovider�s charge for providing the sameservice to persons not entitled to WisconsinMedicaid benefits. For providers using a slidingfee scale for specific services, the usual andcustomary charge is the median of theprovider�s charge for the service whenprovided to non-Medicaid patients.

Providers may not discriminate againstWisconsin Medicaid recipients by chargingMedicaid a higher fee for the same servicethan that charged to a private-pay patient. Forproviders who have not established usual andcustomary charges, the usual and customaryfee should be reasonably related to the cost ofproviding the service.

Specific Instructions forPodiatry Services

Routine Foot CareA referring physician is not required to beindicated on the claim when submitting claimsfor routine foot care, but the name of theprimary or attending physician must bedocumented in the recipient�s medical record.When routine foot care services includemultiple digits on either one or both feet,Wisconsin Medicaid reimburses a single feefor the service.

Prep

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AA referring physician is notrequired to be indicated onthe claim when submittingclaims for routine foot care,but the name of the primaryor attending physician mustbe documented in therecipient�s medical record.



If routine foot care is performed in the nursinghome for several nursing home recipients onthe same date of service (DOS), the podiatristmust indicate the procedure code W9102 (Firstpatient, nursing home visit) for a singlerecipient. Wisconsin Medicaid will reimbursethe normal maximum allowable fee for anestablished patient visit for this recipient.Claims for all other recipients seen in thenursing home on that DOS must be submittedindicating the procedure code W9103(Subsequent patients, nursing home visit), andthey will be reimbursed at a reduced rate.Providers should submit a separate claim foreach recipient seen on the same DOS.

Bilateral SurgeriesBilateral surgical procedures are paid at 150%of the maximum fee for the single service.Indicate modifier �50� in Element 24D and aquantity of �1.0� in Element 24G of the CMS1500 claim form. Refer to the list of allowableprocedure codes in Appendix 1 of thishandbook that indicates which procedures maybe billed as bilateral surgical procedures.

Laboratory TestsPodiatrists may be reimbursed for laboratorytests billed as a �complete� procedure or forthe professional component only. A completelaboratory test includes both the professionaland technical components.

Laboratory Tests and Preparation FeesIf a podiatrist obtains a specimen and refers itto an outside laboratory for analysis orinterpretation only, the outside laboratory maybe reimbursed for the complete procedure. Inthis instance, the podiatrist may submit claimsonly for a laboratory handling fee using thehandling fee procedure code.

If a podiatrist performs both the professionaland technical components of a laboratory test,the podiatrist may be reimbursed for the

complete procedure. In this instance, ahandling fee is not allowable.

Additional limitations on submitting claims forhandling fees are as follows:

1. One laboratory handling fee isreimbursable to a podiatrist per recipient,per outside laboratory, per DOS,regardless of the number of specimenssent to the laboratory. A laboratoryhandling fee is allowable only when �yes�is indicated in Element 20 of the CMS1500 claim form.

2. When submitting claims for handling feesfor specimens sent to two or morelaboratories for one recipient on the sameDOS, indicate the number of laboratoriesin the units field in Element 24G of theCMS 1500 claim form and the totalcharges in Element 24F of the CMS 1500claim form.

3. Wisconsin Medicaid denies claims for alaboratory handling fee that do not have�yes� checked for the outside laboratory inElement 20 of the CMS 1500 claim form.

4. The DOS for a laboratory handling feemust be the date the specimen is taken.

Clinical interpretations of laboratory tests arenot separately reimbursable, sinceinterpretations are reimbursed in the paymentfor the patient/podiatrist visit.

McKesson ClaimCheck®

Monitors Medicaid PolicyWisconsin Medicaid monitors claims forcompliance with Medicaid reimbursement policyusing an automated procedure coding reviewsoftware known as McKesson ClaimCheck.This software reviews claims submitted toWisconsin Medicaid for billing inconsistenciesand errors with respect to CPT codes.

Preparing Claims

BBilateral surgical proceduresare paid at 150% of themaximum fee for the singleservice.



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ClaimCheck review may affect claims in oneof 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.

For further information about ClaimCheck,refer to the Medicine and Surgery section ofthe Physician Services Handbook.



Appendix

AAppendix



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Appendix

Appendix 1Allowable Podiatry Services CPT and HCPCS Procedure Codes

Service Type ofService

Current Procedural Terminology (CPT) Codes

2 10060-10061, 10120-10180, 11000-11001, 11040-11043, 11055-11057*, 11100-11101, 11200-11201, 11300-11311, 11400-11426, 11620-11626, 11719*, 11720-11765, 11900-11901, 12001-12005, 12020, 12041-12044, 13160, 15000, 15050-15261, 15350, 15400, 15786-15787, 16000-16010, 17000-17250, 20000-20005,20103, 20200-20205, 20520-20525, 20550, 20600-20605, 20670-20680

2, 8 208162 20924, 27603-27630

2, 8 276372 27638, 27647-27703, 27707, 27808-27823, 27830-27871, 28001-28288, 28289-

28299*, 28300-28360, 28400*, 28405-28530, 28540-28635, 28645-28665, 28675-28760, 28810-28825, 29305-29445, 29450*, 29505-29515, 29540-29580, 29700-29740, 29750*, 29799

8 29891-298922, 8 29893*

Surgery

2 644504, Q, U 73600-73610

4, Q 73615Radiology

4 Q, U 73620-736605 81000-81015, 81025-81099, 82108, 82310-82330, 82728, 83015

5, U, X 83715X 839125 84100, 84550, 85007, 85009, 85014-85041, 86316-86318

5, U, X 86329-863325 87001-87045, 87070, 87075-87076, 87081-87106, 87109-87147, 87158

5, U, X 87164-871665 87176-87184, 87186-87197, 87205-87206

5, U, X 872075 87210-87253, 87260-87272, 87274, 87276, 87278, 87280, 87285-87299, 87301-

87324, 87328-87335, 87340, 87350-87391, 87420-87425, 87430-87450, 87470-87799

5, U, X 879995 88230-88239, 88245-88248, 88263, 88269, 88283, 88289

5, X 88358-88362

PathologyandLaboratory

5 88365* May be billed as a bilateral procedure with modifier �50� in Element 24D of the CMS 1500 claim form.

Refer to the following charts for allowable podiatry services Current Procedural Terminology (CPT) and HealthcareCommon Procedure Coding System (HCPCS) codes. These charts are periodically revised. Refer to Appendix 6 of thishandbook for applicable TOS codes and descriptions.



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Service Type ofService

CPT Codes

1 90782, 90788, 97010-971395 99000-99001

Medicine

1 99070, 99199

1 99201-99203, 99211-99213, 99221-99222, 99231-99232, 99234-992393 99241-99242, 99251-99252, 99261-99262

EvaluationandManagement

1 99281, 99301-99316, 99341-99350, 99499

Service TOS HCPCS* codesMedical andSurgicalSupplies

9 A4490-A4510, A6244

DrugsAdministeredOther ThanOral Method

1 J0120, J0170-J0270, J0280, J0290-J0295, J0350-J0390, J0456-J0470, J0500-J0585,J0600-J0630, J0640, J0690, J0696-J0704, J0710-J0743, J0745-J0850, J0900-J1051,J1060-J1250, J1320-J1438, J1450, J1455-J1560, J1564-J1565, J1580-J1630, J1642-J1750, J1785, J1800, J1815, J1825-J1830, J1840-J1890, J1940-J1955, J1960-J2000, J2150-J2270, J2275-J2352, J2360-J2370, J2405-J2543, J2550-J2765, J2780-J2790, J2800, J2910-J2912, J2920-J2930, J2950-J2995, J3000, J3030-J3070,J3105-J3364, J3370, J3400-J3480, J3490-J3520, J7030-J7050, J7060-J7191, J7194,J7198-J7199, J7310, J7501, J7504-J7505, J7507-J7510, J7516, J7599, J7699-J8499, J8530-J8999

ChemotherapyDrugs

1 J9000-J9150, J9165-J9170, J9181-J9182, J9190-J9211, J9213-J9218, J9230-J9260,J9266, J9270-J9293, J9320-J9999

Q Codes(Temporary)

P Q4029-Q4048

1 S0009, S0016-S0078, S0080-S00815 S3645-S3650

TemporaryNationalCodes (Non-Medicare) 4, Q, U S8035

*HCPCS = Healthcare Common Procedure Coding System.



Appendix

Appendix 2Allowable Podiatry Services Local Codes

All Codes Have Type of Service �1�Service Category Code Description

W6100 Injection, acth gel, 80 unitsW6102 Injection, ampicillin, 1 gmW6104 Injection, bicillin cr, 900/300W6105 Injection, bicillin cr, up to 300,000 unitsW6106 Injection, calcimar, 100 unitsW6107 Injection, calcimar, 200 unitsW6109 Injection, calcium chloride, 10 mlW6110 Injection, cleocin, up to 600 mgW6112 Injection, cortrosyn, 0.25 mgW6114 Injection, depo-medrol, 60 mgW6115 Injection, depo-medrol, 120 mgW6120 Injection, dexamethasone, la 8 mg/mlW6121 Injection, dexamethasone, la 16 mgW6122 Injection, dextrose, 50 mlW6124 Injection, ephedrineW6126 Injection, furosemide, 20 mgW6127 Injection, furosemide, 40 mgW6128 Injection, furosemide, 80 mgW6130 Injection, glucagon, 1 mgW6134 Injection, heparin, 10,000 unitsW6136 Injection, heparin, 20,000 unitsW6137 Injection, heparin, 5,000 unitsW6138 Injection, hydrocortisone, 250 mgW6140 Injection, imferon, 1 mlW6141 Injection, imferon, 3 mlW6142 Injection, isoproterenolW6144 Injection, kantrex, 1 gmW6146 Injection, kefzol, 1 gmW6148 Injection, magnesium sulfateW6152 Injection, nubainW6156 Injection, penicillin g procaine, 900,000 unitsW6157 Injection, penicillin g procaine, 1.2 mil unitsW6158 Injection, penicillin g procaine, 2.4 mil unitsW6159 Injection, penicillin g procaine, 4.8 mil units

Injections

W6160 Injection, penicillin g procaine, 2.4 mil units/probe

Refer to the following charts for allowable podiatry services local codes.



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All Codes Have Type of Service �1�Service Category Code Description

W6161 Injection, penicillin g procaine, 4.8 mil units/probeW6162 Injection, procaineW6168 Injection stadolW6170 Injection susphrineW6172 Injection tensilon, 5 mgW6173 Injection terramycin, 100 mgW6175 Tine/mantoux/ppdW6177 Injection velban, 2 mgW6178 Injection velban, 5 mgW6179 Injection velosef, 250 mgW6180 Injection velosef, 500 mg

Injections (continued)

W6181 Vistaril, 100 mgW9100 New patient, office visitW9101 Established patient, office visitW9102 First patient, nursing home visitW9103 Subsequent patients, nursing home visitW9104 New patient, patient�s residence

Routine foot care

W9105 Established patient, patient�s residence



Appendix

Appendix 3Required Routine Foot Care Diagnosis Codes

ICD-9-CMDiagnosis Code

Description

250.6 Diabetes with neurological manifestations

250.7 Diabetes with peripheral circulatory disorders

250.8 Diabetes with other specified manifestations

333.7 Symptomatic torsion dystonia

335 Anterior horn cell disease

335.0 Werdnig-Hoffmann disease

335.1 Spinal muscular atrophy

335.10 Spinal muscular atrophy, unspecified

335.11 Kugelberg-Welander disease

335.19 Other

335.2 Motor neuron disease

335.20 Amyotrophic lateral sclerosis

335.21 Progressive muscular atrophy

335.22 Progressive bulbar palsy

335.23 Pseudobulbar palsy

335.24 Primary lateral sclerosis

335.29 Other

335.8 Other anterior horn cell diseases

335.9 Anterior horn cell disease, unspecified

336 Other diseases of spinal cord

336.0 Syringomyelia and syringobulbia

336.1 Vascular myelopathies

336.2 Subacute combined degeneration of spinal cord in diseases classified elsewhere

336.3 Myelopathy in other diseases classified elsewhere

336.8 Other myelopathy

336.9 Unspecified disease of spinal cord

337 Disorders of the autonomic nervous system

337.0 Idiopathic peripheral autonomic neuropathy

337.1 Peripheral autonomic neuropathy in disorders classified elsewhere

337.9 Unspecified disorder of autonomic nervous system

340 Multiple sclerosis

341 Other demyelinating diseases of central nervous system

341.0 Neuromyelitis optica

341.1 Schilder�s disease

341.8 Other demyelinating diseases of central nervous system

341.9 Demyelinating disease of central nervous system, unspecified

Refer to the following charts for a list of required routine foot care International Classification of Diseases, NinthRevision, Clinical Modification (ICD-9-CM) diagnosis codes.



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Description

342 Hemiplegia and hemiparesis

343 Infantile cerebral palsy

343.0 Diplegic

343.1 Hemiplegic

343.2 Quadriplegic

343.3 Monoplegic

343.4 Infantile hemiplegia

343.8 Other specified infantile cerebral palsy

343.9 Infantile cerebral palsy, unspecified

344 Other paralytic syndromes

344.1 Paraplegia

353 Nerve root and plexus disorders

353.0 Brachial plexus lesions

353.1 Lumbosacral plexus lesions

353.2 Cervical root lesions, not elsewhere classified

353.3 Thoracic root lesions, not elsewhere classified

353.4 Lumbosacral root lesions, not elsewhere classified

353.5 Neuralgic amyotrophy

353.6 Phantom limb (syndrome)

353.8 Other nerve root and plexus disorders

353.9 Unspecified nerve root and plexus disorder

355 Mononeuritis of lower limb

355.0 Lesion of sciatic nerve

355.1 Meralgia paresthetica

355.2 Other lesion of femoral nerve

355.3 Lesion of lateral popliteal nerve

355.4 Lesion of medial popliteal nerve

355.5 Tarsal tunnel syndrome

355.6 Lesion of plantar nerve

355.7 Other mononeuritis of lower limb

355.8 Mononeuritis of lower limb, unspecified

355.9 Mononeuritis of unspecified site

356 Hereditary and idiopathic peripheral neuropathy

356.0 Hereditary peripheral neuropathy

356.1 Peroneal muscular atrophy

356.2 Hereditary sensory neuropathy

356.3 Refsum�s disease

Appendix 3(Continued)



Appendix


Description

356.8 Other specified idiopathic peripheral neuropathy

356.9 Unspecified

357 Inflammatory and toxic neuropathy

357.0 Acute infective polyneuritis

357.1 Polyneuropathy in collagen vascular disease

357.2 Polyneuropathy in diabetes

357.3 Polyneuropathy in malignant disease

357.4 Polyneuropathy in other diseases classified elsewhere

357.5 Alcoholic polyneuropathy

357.6 Polyneuropathy due to drugs

357.7 Polyneuropathy due to other toxic agents

357.8 Other

357.9 Unspecified

369.0 Profound impairment, both eyes

369.1 Moderate or severe impairment, better eye, profound impairment lesser eye

369.2 Moderate or severe impairment, both eyes

369.3 Unqualified visual less, both eyes

369.4 Legal blindness, as defined in U.S.A.

440.9 Generalized and unspecified atherosclerosis

443 Other peripheral vascular disease

443.0 Raynaud�s syndrome

443.1 Thromboangiitis obliterans (Buerger�s disease)




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Appendix

Appendix 4Allowable Surgical Procedure Codes for Mycotic Conditions

CPT ProcedureCode

Description

10060 Incision and drainage of abcess (eg, carbuncle, suppurative hidradenitis, cutaneousor subcutaneous abcess, cyst, furuncle, or paronychia); simple or single

10061 complicated or multiple

11000 Debridement of extensive eczematous or infected skin; up to 10% of body surface

11001 each additional 10% of body surface

11055 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion

11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simpleclosure), unless otherwise listed (separate procedure); single lesion

11101 each separate/additional lesion

11720 Debridement of nail(s) by any method(s); one to five

11721 six or more

11730 Avulsion of nail plate, partial or complete, simple; single

11732 each additional nail plate

11750 Excision of nail and nail matrix, partial or complete, (eg, ingrown or deformed nail)for permanent removal;

17000 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgicalcurettement), all benign or premalignant lesions (eg, actinic keratoses) other thanskin tags or cutaneous vascular proliferative lesions; first lesion

17003 second through 14 lesions, each

17004 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgicalcurettement), all benign or premalignant lesions (eg, actinic keratoses) other thanskin tags or cutaneous vascular proliferative lesions; 15 or more lesions

Refer to the following chart for a list of allowable surgical Current Procedural Terminology (CPT) codes for mycoticconditions.



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Appendix

Appendix 5Allowable Diagnosis Codes for Mycotic Conditions and Mycotic Nails


Description

039 Actinomycotic infections

039.4 Madura foot

110.1 Dermatophytosis of nail

110.4 Dermatophytosis of foot

111 Dermatomycosis, other and unspecified

111.0 Pityriasis versicolor

111.1 Tinea nigra

111.2 Tinea blanca

111.3 Black piedra

111.8 Other specified dermatomycoses

111.9 Dermatomycosis, unspecified

112 Candidiasis

112.3 Candidiasis of skin and nails

116 Blastomycotic infection

116.0 Blastomycosis

116.1 Paracoccidioidomycosis

116.2 Lobomycosis

117 Other mycoses

117.0 Rhinosporidiosis

117.1 Sporotrichosis

117.2 Chromoblastomycosis

117.3 Aspergillosis

117.4 Mycotic mycetomas

117.5 Cryptococcosis

117.6 Allescheriosis (Petriellidosis)

117.7 Zygomycosis (Phycomycosis or Mucormycosis)

117.8 Infection by dematiacious fungi, (Phaehyphomycosis)

117.9 Other and unspecified mycoses

118 Opportunistic mycoses

703.8 Other specified diseases of nail

Refer to the following chart for a list of allowable International Classification of Diseases, Ninth Revision, ClinicalModification (ICD-9-CM) diagnosis codes for mycotic conditions and mycotic nails.



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Appendix

Appendix 6Copayment Amounts and Allowable Podiatry Type of Service and

Place of Service Codes

Podiatry Services Copayments*

Medicaid Maximum Allowable Fee Copayment

Office visits. Each service costing:

• Up to $10.00 $0.50

• From $10.01 to $25.00 $1.00

• From $25.01 to $50.00 $2.00

• Over $50.00 $3.00

Each surgery $3.00

Each laboratory service $1.00

Each X-ray service $3.00

Routine foot care $1.00

*A $30 calendar year copayment limit per

year, per recipient, per provider applies.

Type of Service CodesCode Description

1 Medical

2 Surgical

3 Consultation

4 Total charge � diagnostic X-ray orultrasound

5 Total charge � diagnostic laboratory

B Total charge � diagnostic medical

Q Professional component � diagnosticX-ray or ultrasound

U Technical component � diagnosticX-ray or ultrasound

W Technical component � diagnosticmedical

X Professional component � diagnosticlaboratory

Place of Service CodesCode Description

1 Inpatient hospital

2 Outpatient hospital

3 Office

4 Home

7 Nursing home

8 Skilled nursing facility

B Ambulatory surgical center

Refer to the following charts for copayment amounts and allowable podiatry type of service and place of service codes.



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Appendix

Appendix 7Completion Instructions for the CMS 1500 Claim Form

Use the following claim form completion instructions, not the claim form�s printed descriptions, to avoid denial or inaccurateclaim payment. Do not include attachments unless instructed to do so. Complete the elements listed below as appropriate.

Note: Medicaid providers should always verify recipient eligibility before rendering services.

Element 1 � Program Block/Claim Sort IndicatorEnter claim sort indicator �P� in the Medicaid check box for the service billed.

Element 1a � Insured�s I.D. NumberEnter the recipient�s 10-digit Medicaid identification number. Do not enter any other numbers or letters.

Element 2 � Patient�s NameEnter the recipient�s last name, first name, and middle initial. Use the Eligibility Verification System (EVS) to obtain thecorrect spelling of the recipient�s name. If the name or spelling of the name on the Medicaid identification card and the EVSdo not match, use the spelling from the EVS.

Element 3 � Patient�s Birth Date, Patient�s SexEnter the recipient�s birth date in MM/DD/YY format (e.g., February 3, 1955, would be 02/03/55) or in MM/DD/YYYYformat (e.g., February 3, 1955, would be 02/03/1955). Specify if the recipient is male or female by placing an �X� in theappropriate box.

Element 4 � Insured�s Name (not required)

Element 5 � Patient�s AddressEnter the complete address of the recipient�s place of residence.

Element 6 � Patient Relationship to Insured (not required)

Element 7 � Insured�s Address (not required)

Element 8 � Patient Status (not required)

Element 9 � Other Insured�s NameThird-party insurance (commercial health insurance coverage) must be billed prior to billing Wisconsin Medicaid, unless theservice does not require third-party billing as determined by Wisconsin Medicaid.

When the recipient has Wausau Health Protection Plan (�HPP�), BlueCross & BlueShield (�BLU�), Wisconsin PhysiciansService (�WPS�), TriCare (�CHA�), or some other (�OTH�) commercial health insurance, and the service requires third-party billing according to the Coordination of Benefits section of the All-Provider Handbook, then one of the following threeother insurance (OI) explanation codes must be indicated in the first box of Element 9. The description is not required, nor isthe policyholder, plan name, group number, etc. (Elements 9a, 9b, 9c, and 9d are not required.)

Code DescriptionOI-P PAID by health insurance. In Element 29 of this claim form, indicate the amount paid by commercial health

insurance to the provider or to the insured.OI-D DENIED by health insurance following submission of a correct and complete claim, or payment was applied

towards the coinsurance and deductible. Do not use this code unless the claim was actually billed to the commercialhealth insurer.



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OI-Y YES, the recipient has commercial health insurance, but it was not billed for reasons including, but not limited to:� The recipient denied coverage or will not cooperate.� The provider knows the service in question is not covered by the carrier.� The recipient�s commercial health insurance failed to respond to initial and follow-up claims.� Benefits are not assignable or cannot get assignment.

When the recipient is a member of a commercial HMO, one of the following must be indicated, if applicable:

Code DescriptionOI-P PAID by commercial HMO. The amount paid is indicated on the claim.OI-H HMO does not cover this service or the billed amount does not exceed the coinsurance or deductible amount.

Important note: The provider may not use OI-H if the commercial HMO denied payment because an otherwise coveredservice was not rendered by a designated provider. Services covered by a commercial HMO are not reimbursable byWisconsin Medicaid except for the copayment and deductible amounts. Providers who receive a capitation payment fromthe commercial HMO may not bill Wisconsin Medicaid for services which are included in the capitation payment.

Element 10 � Is Patient�s Condition Related to (not required)

Element 11 � Insured�s Policy, Group, or FECA NumberUse the first box of this element for Medicare information. (Elements 11a, 11b, 11c, and 11d are not required.) Bill Medicarebefore billing Wisconsin Medicaid.

Element 11 should be left blank when one or more of the following statements is true:

� Medicare never covers the procedure in any circumstance.� The recipient�s Wisconsin Medicaid file shows he or she does not have any Medicare coverage for the service

provided. For example, the service is covered by Medicare Part A, but the recipient does not have Medicare Part A.Services related to a diagnosis of chronic renal failure are the only exceptions.

� The non-physician provider�s Wisconsin Medicaid file shows he or she is not Medicare certified. (This does not apply tophysicians because Medicare will retroactively certify physicians for the date and the service provided if they held avalid license when the service was performed.)

� Medicare has allowed the charges. In this case, attach the Explanation of Medicare Benefits, but do not indicate on theclaim form the amount Medicare paid.

If none of the above is true, a Medicare disclaimer code is necessary.

The following Medicare disclaimer codes may be used when appropriate:

Code DescriptionM-1 Medicare benefits exhausted. This code may be used when Medicare has denied the charges because the

recipient�s lifetime benefit, spell of illness, or yearly allotment of available benefits is exhausted. Use the M-1disclaimer in these two instances only:

For Medicare Part A (all three criteria must be met):

� The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A.� The recipient is eligible for Medicare Part A.� The service provided is covered by Medicare Part A but is not payable due to benefits being exhausted.




Appendix

For Medicare Part B (all three criteria must be met):

� The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B.� The recipient is eligible for Medicare Part B.� The service provided is covered by Medicare Part B but is not payable due to benefits being exhausted.

M-5 Provider is not Medicare certified. This code may be used when providers are identified in Wisconsin Medicaidfiles as being Medicare certified, but are billing for a date of service (DOS) before or after their Medicarecertification effective dates. Use M-5 in these two instances only:


� The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A but not for the date theservice was provided.

� The recipient is eligible for Medicare Part A.� The procedure provided is covered by Medicare Part A.


� The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B but not for the date theservice was provided.

� The recipient is eligible for Medicare Part B.� The procedure provided is covered by Medicare Part B.

M-7 Medicare disallowed or denied payment. This code applies when Medicare denies the claim for reasonsrelated to policy, not billing errors. Use M-7 in these two instances only:


� The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A.� The recipient is eligible for Medicare Part A.� The service is covered by Medicare Part A but is denied by Medicare Part A due to frequency limitations,

diagnosis restrictions, etc.


� The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B.� The recipient is eligible for Medicare Part B.� The service is covered by Medicare Part B but is denied by Medicare Part B due to frequency limitations,

diagnosis restrictions, etc.

M-8 Noncovered Medicare service. This code may be used when Medicare was not billed because the service,under certain circumstances related to the recipient�s diagnosis, is not covered. Use M-8 in these two instancesonly:


� The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A.� The recipient is eligible for Medicare Part A.




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� The service is usually covered by Medicare Part A but not under certain circumstances related to therecipient�s diagnosis.


� The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B.� The recipient is eligible for Medicare Part B.� The service is usually covered by Medicare Part B but not under certain circumstances related to the

recipient�s diagnosis.

Elements 12 and 13 � Authorized Person�s Signature (not required)

Element 14 � Date of Current Illness, Injury, or Pregnancy (not required)

Element 15 � If Patient Has Had Same or Similar Illness (not required)

Element 16 � Dates Patient Unable to Work in Current Occupation (not required)

Elements 17 and 17a � Name and I.D. Number of Referring Physician or Other SourceWhen appropriate, enter the referring physician�s name and six-character Universal Provider Identification Number(UPIN). If the UPIN is not available, enter the eight-digit Medicaid provider number or the license number of the referringphysician.

Element 18 � Hospitalization Dates Related to Current Services (not required)

Element 19 � Reserved for Local UseIf the provider bills an unlisted (or not otherwise specified) procedure code, the provider must describe the procedure. IfElement 19 does not provide enough space for the procedure description, or if the provider is billing multiple unlistedprocedure codes, the provider must attach documentation to the claim describing the procedure(s). In this instance, indicate�See Attachment� in Element 19. Do not bill unlisted procedure codes through electronic billing. Unlisted procedure codesare required to be submitted through paper claims submission.

Element 20 � Outside Lab?If a laboratory handling fee is billed, check �yes� to indicate that the specimen was sent to an outside lab. Otherwise thiselement is not required.

Element 21 � Diagnosis or Nature of Illness or InjuryEnter the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codefor each symptom or condition related to the services provided. List the primary diagnosis first. Etiology (�E�) andmanifestation (�M�) codes may not be used as a primary diagnosis. The diagnosis description is not required.

Element 22 � Medicaid Resubmission (not required)

Element 23 � Prior Authorization Number (not required)

Element 24A � Date(s) of ServiceEnter the month, day, and year for each procedure using the following guidelines:

� When billing for one DOS, enter the date in MM/DD/YY or MM/DD/YYYY format in the �From� field.� When billing for two, three, or four DOS on the same detail line, enter the first DOS in MM/DD/YY or MM/DD/

YYYY format in the �From� field, and subsequent DOS in the �To� field by listing only the date(s) of the month (i.e.,DD, DD/DD, or DD/DD/DD).




Appendix

It is allowable to enter up to four DOS per line if:

� All DOS are in the same calendar month.� All services are billed using the same procedure code and modifier, if applicable.� All procedures have the same type of service (TOS) code.� All procedures have the same place of service (POS) code.� All procedures were performed by the same provider.� The same diagnosis is applicable for each procedure.� The charge for all procedures is identical. (Enter the total charge per detail line in Element 24F.)� The number of services performed on each DOS is identical.� All procedures have the same HealthCheck or family planning indicator.� All procedures have the same emergency indicator.

Element 24B � Place of ServiceEnter the appropriate Medicaid single-digit POS code for each service.

Element 24C � Type of ServiceEnter the appropriate Medicaid single-digit TOS code for each service.

Element 24D � Procedures, Services, or SuppliesEnter the single most appropriate five-character Current Procedural Terminology (CPT) or Healthcare CommonProcedure Coding System (HCPCS) code. Claims received without an appropriate procedure code are denied by WisconsinMedicaid.

ModifiersEnter the appropriate two-character modifier in the �Modifier� column of Element 24D. Use modifier �50� to indicate abilateral procedure. Please note that Wisconsin Medicaid has not adopted all CPT, HCPCS, or Medicare modifiers.

Element 24E � Diagnosis CodeEnter the number (1, 2, 3, or 4) that corresponds to the appropriate diagnosis code listed in Element 21.

Element 24F � $ ChargesEnter the total charge for each line item.

Element 24G � Days or UnitsEnter the appropriate number of units, time units, qualifying circumstance units, or other services billed for each line item.Always use a decimal (e.g., 2.0 units).

Element 24H � EPSDT/Family PlanEnter an �H� for each procedure that was performed as a result of a HealthCheck (EPSDT) referral. If HealthCheck doesnot apply, leave this element blank.

Element 24I � EMGEnter an �E� for each procedure performed as an emergency, regardless of the POS. If the procedure is not an emergency,leave this element blank.




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Element 24J � COB (not required)

Element 24K � Reserved for Local UseEnter the eight-digit Medicaid provider number of the performing provider for each procedure, if the billing provider indicatedin Element 33 belongs to a physician clinic or group.

Any other information entered in this element may cause claim denial.

Element 25 � Federal Tax I.D. Number (not required)

Element 26 � Patient�s Account No.Optional � provider may enter up to 12 characters of the patient�s internal office account number. This number will appearon the Remittance and Status Report.

Element 27 � Accept Assignment (not required)

Element 28 � Total ChargeEnter the total charges for this claim.

Element 29 � Amount PaidEnter the amount paid by other insurance. If the other insurance denied the claim, enter $0.00. (If a dollar amount isindicated in Element 29, �OI-P� must be indicated in Element 9.) Do not enter Medicare-paid amounts in this field.

Element 30 � Balance DueEnter the balance due as determined by subtracting the amount paid in Element 29 from the amount in Element 28.

Element 31 � Signature of Physician or SupplierThe provider or the authorized representative must sign in Element 31. The month, day, and year the form is signed mustalso be entered in MM/DD/YY or MM/DD/YYYY format.

Note: The signature may be a computer-printed or typed name and date, or a signature stamp with the date.

Element 32 � Name and Address of Facility Where Services Were RenderedIf the services were provided to a recipient in a nursing home, indicate the nursing home�s eight-digit Wisconsin Medicaidprovider number.

Element 33 � Physician�s, Supplier�s Billing Name, Address, ZIP Code, and Phone #Enter the provider�s name (exactly as indicated on the provider�s notification of certification letter) and address of the billingprovider. At the bottom of Element 33, enter the billing provider�s eight-digit Medicaid provider number.




Appendix

Appendix 8Completed Sample of the CMS 1500 Claim Form

P

Recipient, Im A.

609 Willow

Anytown WI

55555 XXX XXX-XXXX

OI-P

MM DD YY X

1234567890

726.90

735.4

MM DD YY 3 1 99202 1 2 XX XX 1

MM DD YY 3 4 73620 1 2 XX XX 2

XXX XX XX XX XX XX

IM Authorized MM/DD/YY

I.M. Billing1 W. WilliamsAnytown, WI 55555 87654321



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Glossary

AdjustmentA modified or changed claim that was originally allowed, atleast in part, by Wisconsin Medicaid.

Allowed claimA Medicaid or Medicare claim that has at least one servicethat is reimbursable.

BadgerCareBadgerCare extends Medicaid coverage through aMedicaid expansion under Titles XIX and XXI to uninsuredchildren and parents with incomes at or below 185% of thefederal poverty level and who meet other programrequirements. The goal of BadgerCare is to fill the gapbetween Medicaid and private insurance withoutsupplanting or �crowding out� private insurance.

BadgerCare benefits are identical to the benefits andservices covered by Wisconsin Medicaid and recipients�health care is administered through the same deliverysystem.

CMSCenters for Medicare and Medicaid Services. An agencyhoused within the U.S. Department of Health and HumanServices (DHHS), CMS administers Medicare, Medicaid,related quality assurance programs, and other programs.Formerly known as the Health Care FinancingAdministration (HCFA).

CPTCurrent Procedural Terminology. A listing of descriptiveterms and codes for reporting medical, surgical, therapeutic,and diagnostic procedures. These codes are developed,updated, and published annually by the American MedicalAssociation and adopted for billing purposes by the Centersfor Medicare and Medicaid Services (CMS), formerlyHCFA, and Wisconsin Medicaid.

Crossover claimA Medicare-allowed claim for a dual entitlee submitted toWisconsin Medicaid for possible additional payment of theMedicare coinsurance and deductible.

DHCFDivision of Health Care Financing. The DHCF administersWisconsin Medicaid for the Department of Health andFamily Services (DHFS) under statutory provisions,administrative rules, and the state�s Medicaid plan. Thestate�s Medicaid plan is a comprehensive description of thestate�s Medicaid program that provides the Centers forMedicare and Medicaid Services (CMS) and the U.S.Department of Health and Human Services (DHHS)assurances that the program is administered in conformitywith federal law and CMS policy.

DHFSDepartment of Health and Family Services. The DHFSadministers Wisconsin Medicaid. Its primary mission is tofoster healthy, self-reliant individuals and families bypromoting independence and community responsibility;strengthening families; encouraging healthy behaviors;protecting vulnerable children, adults, and families;preventing individual and social problems; and providingservices of value to taxpayers.

DHHSDepartment of Health and Human Services. The UnitedStates government�s principal agency for protecting thehealth of all Americans and providing essential humanservices, especially for those who are least able to helpthemselves.

The DHHS includes more than 300 programs, covering awide spectrum of activities, including overseeing Medicareand Medicaid; medical and social science research;preventing outbreak of infectious disease; assuring food anddrug safety; and providing financial assistance for low-income families.

DOSDate of service. The calendar date on which a specificmedical service is performed.

Dual entitleeA recipient who is eligible for both Medicaid and Medicare,either Medicare Part A, Part B, or both.

GGlossary of Common Terms



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ECSElectronic Claims Submission. Claims transmitted via thetelephone line and fed directly into Wisconsin Medicaid�sclaims processing subsystem.

Emergency servicesThose services which are necessary to prevent death orserious impairment of the health of the individual.

EOBExplanation of Benefits. Appears on the provider�sRemittance and Status (R/S) Report and notifies theMedicaid provider of the status or action taken on a claim.

EVSEligibility Verification System. Wisconsin Medicaidencourages all providers to verify eligibility before renderingservices, both to determine eligibility for the current dateand to discover any limitations to a recipient�s coverage.Providers may access recipient eligibility informationthrough the following methods:

� Automated Voice Response (AVR) system.� Magnetic stripe card readers.� Personal computer software.� Provider Services (telephone correspondents).� Direct Information Access Line with Updates for

Providers (Dial-Up).

Fee-for-serviceThe traditional health care payment system under whichphysicians and other providers receive a payment for eachunit of service provided rather than a capitation payment foreach recipient.

Fiscal agentThe Medicaid fiscal agent (EDS) is under contract with theDepartment of Health and Family Services (DHFS) tocertify providers, process and pay claims, answer providerand recipient questions, issue identification cards torecipients, publish information for providers and recipients,and maintain the Wisconsin Medicaid Web site.

HCPCSHealthcare Common Procedure Coding System. A listing ofservices, procedures, and supplies offered by physicians andother providers. HCPCS includes Current ProceduralTerminology (CPT) codes, national alphanumeric codes,and local alphanumeric codes. The national codes are

developed by the Centers for Medicare and MedicaidServices (CMS), formerly HCFA, to supplement CPTcodes. Formerly known as HCFA Common ProcedureCoding System.

HealthCheckProgram which provides Medicaid-eligible children underage 21 with regular health screenings.

ICD-9-CMInternational Classification of Diseases, Ninth Revision,Clinical Modification. Nomenclature for medicaldiagnoses required for billing. Available through theAmerican Hospital Association.

Maximum allowable fee scheduleA listing of all procedure codes allowed by WisconsinMedicaid for a given provider type and the maximumallowable fee and relative value units (RVUs) WisconsinMedicaid assigns to each procedure code.

MedicaidMedicaid is a joint federal/state program established in 1965under Title XIX of the Social Security Act to pay formedical services for people with disabilities, people 65 yearsand older, children and their caretakers, and pregnantwomen who meet the program�s financial requirements.

The purpose of Medicaid is to provide reimbursement forand assure the availability of appropriate medical care topersons who meet the criteria for Medicaid. Medicaid isalso known as the Medical Assistance Program, Title XIX,or T19.

Medically necessaryAccording to HFS 101.03(96m), Wis. Admin. Code, aservice that is:

(a) Required to prevent, identify or treat a recipient�sillness, injury or disability; and

(b) Meets the following standards:1. Is consistent with the recipient�s symptoms or with

prevention, diagnosis or treatment of the recipient�sillness, injury or disability;

2. Is provided consistent with standards ofacceptable quality of care applicable to type ofservice, the type of provider and the setting inwhich the service is provided;



Glossary

3. Is appropriate with regard to generally acceptedstandards of medical practice;

4. Is not medically contraindicated with regard to therecipient�s diagnoses, the recipient�s symptoms orother medically necessary services being providedto the recipient;

5. Is of proven medical value or usefulness and,consistent with s. HFS 107.035, is not experimentalin nature;

6. Is not duplicative with respect to other servicesbeing provided to the recipient;

7. Is not solely for the convenience of the recipient,the recipient�s family or a provider;

8. With respect to prior authorization of a service andto other prospective coverage determinations madeby the department, is cost-effective compared to analternative medically necessary service which isreasonably accessible to the recipient; and

9. Is the most appropriate supply or level of servicethat can safely and effectively be provided to therecipient.

PayeeParty to whom checks are made payable. The payee�saddress is used as the mailing address for checks andRemittance and Status (R/S) Reports.

POSPlace of service. A single-digit code which identifies theplace where the service was performed.

QMB OnlyQualified Medicare Beneficiary under the MedicareCatastrophic Health Act. These recipients are only eligiblefor the payment of the coinsurance and the deductible forMedicare-allowed claims.

Qualifying circumstancesConditions that complicate the rendering of anesthesiaservices, including the extraordinary condition of the patient,special operative conditions, and unusual risk factors.

R/S ReportRemittance and Status Report. A statement generated bythe Medicaid fiscal agent to inform the provider regardingthe processing of the provider�s claims.

RVURelative value unit. A number assigned by WisconsinMedicaid to indicate the relative clinical intensity anddifficulty of the surgical, diagnostic, or therapeuticprocedure code for which anesthesia services wereperformed. Relative value units are not necessarilyequivalent to either federal or American Society ofAnesthesiologists RVUs. Relative value units are indicatedon the Physician Maximum Allowable Fee Schedule.

TOSType of service. A single-digit code which identifies thegeneral category of a procedure code.



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Index

IIndexBilled amounts, 18

Certification, 5

ClaimsComponents, 18

Billed amounts, 18Diagnosis codes, 18, 27, 33Procedure codes, 18, 23, 25, 31

CMS 1500, see CMS 1500 claim formPreparing, 17Reimbursement, 17

Documentation requirements, 18Specific claims submission instructions, 18

Bilateral surgeries, 19Laboratory tests, 19Routine foot care, 18

Submission process, 17Deadline, 17Electronic Submission, 17Paper, 17Where to send, 17

Clinical Certification for Laboratory Services (CLIA), 11

CMS 1500 claim formCompleted sample, 43How to obtain, 17Instructions, 37

Copayment, 5, 35

Diagnosis codes, 18, 27, 33

Drugs/injections, 12Corticosteroid injections, 13Covered procedure codes, 12Other injections, 13Prescriptions for drugs, 13Reimbursement, 12Vitamin B-12, 13

Evaluation and management (E&M) services, 8Ancillary providers, 9Established patient, 8Limitations, 9Office located in hospital, 8Office visits and counseling, 8New patient, 8

General information, 5Provider, 5

Eligibility, 5Certification, 5Scope of service, 5

Recipient, 5Copayment, 5Eligibility, 5

Laboratory, 11Complete procedure vs. professional and technical

components, 11CLIA enrollment, 11Further CLIA information, 11

Local codes, 25

McKesson ClaimCheck®, 19

Maximum fee schedule, 17

Medical necessity, 7

Noncovered services, 15

Physical medicine, 10

Place of service codes, 35

Prescriptions for drugs, 13Compound drugs, 15Drug utilization review system, 15General prescription requirements, 13Over-the-counter drugs, 15Prescribing brand-name legend drugs, 14Prescribing drugs manufactured by companies who have

not signed the rebate agreement, 14

Procedure codes, 18, 23, 25, 31

Provider information, 5Certification, 5Eligibility, 5Scope of service, 5

Radiology, 12Complete procedure vs. professional and technical

components, 12



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Recipient eligibility, 5

Reimbursement, 17

Scope of service, 5

Services, 7Covered podiatry services, 7Drugs/Injections, 12Evaluation and management services, 8Laboratory, 11Noncovered services, 15Physical medicine, 10Prescriptions for drugs, 13Radiology, 12Surgical procedures, 9

Surgical procedures, 9Casting/strapping/taping, 10Limitations, 9Mycotic conditions and mycotic nails, 10

Limitations applicable to mycotic conditions and mycoticnails, 10

Allowable diagnosis codes for mycotic conditions andmycotic nails, 33

Allowable surgical procedure codes for mycoticconditions, 31

Routine foot care, 9Limitations to routine foot care, 10Required routine foot care diagnosis codes, 27

Type of service codes, 35

Documents

Wisconsin Medicaid Podiatry Services Handbook · The Division of Health Care Financing (DHCF) is pleased to provide you with a copy of the new Podiatry Services Handbook. All policies