Wisconsin Medicaid Podiatry Services Handbook

Podiatry Services Handbook

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

James E. Doyle Governor

Helene Nelson Secretary

State of Wisconsin Department of Health and Family Services

M E M O R A N D U M

DIVISION OF HEALTH CARE FINANCING

1 WEST WILSON STREET P O BOX 309

MADISON WI 53701-0309

Telephone: 608-266-8922

FAX: 608-266-1096

TTY: 608-261-7798 dhfs.state.wi.us

DATE:

February 24, 2003

TO:

Podiatrists, Managed Care Organizations

FROM:

Peggy B. Handrich, Administrator Division 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 new Podiatry Services Handbook.

All policies included in the handbook are effective for dates of service on and after May 1, 2003.

ARCHIVAL USE ONLY Please utilize your current handbook, Part V, the Podiatry Handbook, until that date. Refer to the Online Handbook The Podiatry Services Handbook incorporates current Medicaid podiatry policy information into

a single reference source. The handbook replaces all prior podiatry services publications including Part V, the Podiatry Handbook, dated January 1992.

for current policy This handbook does not replace the All-Provider Handbook and all-provider Wisconsin Medicaid

and BadgerCare Updates, the Wisconsin Administrative Code, or Wisconsin Statutes. Subsequent changes to podiatry services policies will be published first in Wisconsin Medicaid and 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 be downloaded from the Medicaid Web site at dhfs.state.wi.us/medicaid/.

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



IImportant Telephone Numbers Wisconsin Medicaid's Eligibility Verification System (EVS) is available through the following resources to verify checkwrite information, claim status, prior authorization status, provider certification, and/or recipient eligibility:

Service

Information Available

Telephone Number

Hours

Automated Voice Response (AVR) System

(Computerized voice

response to provider

inquiries.)

Checkwrite Information Claim Status Prior Authorization Status Recipient Eligibility*

(800) 947-3544

(608) 221-4247 (Madison area)

24 hours a day/ 7 days a week

Personal Computer Software and Magnetic Stripe Card Readers

Recipient Eligibility*

Refer to Provider Resources section of the All-Provider Handbook for a list of commercial eligibility verification vendors.

24 hours a day/ 7 days a week

Provider Services Checkwrite Information (800) 947-9627

Policy/Billing and Eligibility:

(Correspondents

Claim Status

(608) 221-9883

8:30 a.m. - 4:30 p.m. (M, W-F)

assist with questions.)

ARCHIVAL USE ONLY Prior Authorization Status

9:30 a.m. - 4:30 p.m. (T) Pharmacy:

Refer to the Online Handbook Provider Certification

8:30 a.m. - 6:00 p.m. (M, W-F) 9:30 a.m. - 6:00 p.m. (T)

Recipient Eligibility*

for current policy Direct Information Checkwrite Information Call (608) 221-4746

Access Line with Updates for Providers (Dial-Up)

Claim Status

Prior Authorization Status

for more information.

(Software

Recipient Eligibility*

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

communications

package and

modem.)

Recipient Services (Recipients or persons calling on behalf of recipients only.)

Recipient Eligibility

Medicaid-Certified Providers

General Medicaid Information

(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 patient information 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 .................................................................................................... 5 Scope of Service ...................................................................................................... 5 Provider Eligibility and Certification ............................................................................ 5 Recipient Information ................................................................................................... 5 Recipient Eligibility .................................................................................................. 5 Copayment............................................................................................................. 5

Services........................................................................................................................... 7 Covered Podiatry Services ............................................................................................. 7 Medical Necessity .................................................................................................... 7 Evaluation and Management Services .............................................................................. 8 Established Patient .................................................................................................. 8 New Patient ............................................................................................................ 8

ARCHIVAL USE ONLY Office Located in Hospital ......................................................................................... 8

Office Visits and Counseling ...................................................................................... 8

Refer to the Online Handbook Limitations Applicable to Evaluation and Management Procedure Codes.......................... 9

Ancillary Providers .................................................................................................. 9

for current policy Surgical Procedures ...................................................................................................... 9 Limitations Applicable to Surgical Procedures .............................................................. 9 Routine Foot Care .................................................................................................. 10 Limitations Applicable to Routine Foot Care .......................................................... 10 Mycotic Conditions and Mycotic Nails ......................................................................... 10 Limitations Applicable to Mycotic Conditions and Mycotic Nails................................. 10 Casting/Strapping/Taping ........................................................................................ 10 Physical Medicine ........................................................................................................ 11 Laboratory ................................................................................................................. 11

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

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

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

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

PHC 1417

Prescriptions for Drugs ................................................................................................ 13 General Prescription Requirements ........................................................................... 13 Prescribing Brand-Name Legend Drugs ..................................................................... 14 Prescribing Drugs Manufactured by Companies Who Have Not Signed the Rebate Agreement ....................................................................................................... 14 Over-the-Counter Drugs .......................................................................................... 15 Compound Drugs .................................................................................................. 15 Drug Utilization Review System ................................................................................ 15

Noncovered Services.................................................................................................... 15 Preparing Claims ............................................................................................................. 17

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

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

Claim Components ...................................................................................................... 18 Procedure Codes .................................................................................................... 18 Diagnosis Codes .................................................................................................... 18

ARCHIVAL USE ONLY Billed Amounts ...................................................................................................... 18

Specific Instructions for Podiatry Services ....................................................................... 18

Refer to the Online Handbook Routine Foot Care .................................................................................................. 18

Bilateral Surgeries .................................................................................................. 19

for current policy Laboratory Tests..................................................................................................... 19 Laboratory Tests and Preparation Fees .................................................................. 19 McKesson ClaimCheck? Monitors Medicaid Policy ............................................................. 19 Appendix ....................................................................................................................... 21 1. Allowable Podiatry Services CPT and HCPCS Procedure Codes .......................................... 23 2. Allowable Podiatry Services Local Codes ......................................................................... 25 3. Required Routine Foot Care Diagnosis Codes .................................................................. 27 4. Allowable Surgical Procedure Codes for Mycotic Conditions............................................... 31 5. Allowable Diagnosis Codes for Mycotic Conditions and Mycotic Nails .................................. 33 6. Copayment Amounts and Allowable Podiatry Type of Service and Place of Service Codes ..... 35 7. Completion Instructions for the CMS 1500 Claim Form .................................................... 37 8. Completed Sample of the CMS 1500 Claim Form ............................................................ 43 Glossary of Common Terms .............................................................................................. 45

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

PPreface

The Wisconsin Medicaid and BadgerCare Podiatry Services Handbook is issued to podiatrists that are Wisconsin Medicaid certified. It contains information that applies to fee-for-service Medicaid providers. The

Handbook Organization

The Podiatry Services Handbook consists of the following chapters:

Medicaid information in the handbook applies to both Wisconsin Medicaid and BadgerCare.

? General Information. ? Services.

? Preparing Claims.

Wisconsin Medicaid and BadgerCare are administered by the Department of Health and Family Services (DHFS). Within the DHFS, the Division of Health Care Financing (DHCF) is directly responsible for managing Wisconsin Medicaid and BadgerCare. As of January 2003,

In addition to the Podiatry Services Handbook, each Medicaid-certified podiatrist is issued a copy of the AllProvider Handbook. The All-Provider Handbook includes the following sections:

BadgerCare extends Medicaid coverage to uninsured

? Claims Submission.

children and parents with incomes at or below 185% of

? Coordination of Benefits.

the federal poverty level and who meet other program

? Covered and Noncovered Services.

requirements. BadgerCare recipients receive the same

? PriorAuthorization.

health benefits as Wisconsin Medicaid recipients and their ? Provider Certification.

health care is administered through the same delivery

? Provider Resources.

system.

? Provider Rights and Responsibilities.

ARCHIVAL USE ONLY Medicaid and BadgerCare recipients enrolled in state-

? Recipient Rights and Responsibilities.

Refer to the Online Handbook contracted HMOs are entitled to at least the same

benefits as fee-for-service recipients; however, HMOs

Legal Framework of Wisconsin

for current policy may establish their own requirements regarding prior

authorization, billing, etc. If you are an HMO network

Medicaid and BadgerCare

provider, contact your managed care organization

The following laws and regulations provide the legal

regarding its requirements. Information contained in this

framework for Wisconsin Medicaid and BadgerCare:

and other Medicaid publications is used by the DHCF to

resolve disputes regarding covered benefits that cannot be handled internally by HMOs under managed care arrangements.

Federal Law and Regulation

? Law: United States Social Security Act; Title XIX (42 US Code ss.1396 and following) and Title XXI.

Verifying Eligibility

? Regulation: Title 42 CFR Parts 430-498 -- Public Health.

Wisconsin Medicaid providers should always verify a recipient's eligibility before providing services, both to determine eligibility for the current date and to discover any limitations to the recipient's coverage. Wisconsin Medicaid's Eligibility Verification System (EVS) provides eligibility information that providers can access a number of ways.

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

Wisconsin Law and Regulation

? Law: Wisconsin Statutes: Sections 49.43-49.499 and 49.665.

? Regulation: WisconsinAdministrative Code, Chapters HFS 101-108.

Handbooks and Wisconsin Medicaid and BadgerCare Updates further interpret and implement these laws and regulations.

3 Podiatry Services Handbook u May 2003

Handbooks and Updates, maximum allowable fee schedules, helpful telephone numbers and addresses, and much more information about Wisconsin Medicaid and BadgerCare are available at the following Web sites:

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

Medicaid Fiscal Agent

The DHFS contracts with a fiscal agent, which is currently EDS.

ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

4 Wisconsin Medicaid and BadgerCare u May 2003

General Information

GGeneral Information

TThe policies in the Podiatry Services Handbook govern services provided within the scope of practice of the profession as defined in s. 448.60(4), Wis. Stats.

Provider Information

Scope of Service The policies in the Podiatry Services Handbook govern services provided within the scope of practice of the profession as defined in s.448.60(4), Wis. Stats.

Provider Eligibility and Certification To become a Wisconsin Medicaid-certified podiatrist under HFS 105.265, Wis. Admin. Code, providers must be currently licensed to practice podiatry in Wisconsin, pursuant to s. 448.63(1), Wis. Stats., and registered under Pod. 4.01, Wis. Admin. Code.

Copayment amounts are determined per procedure code per date of service as listed in Appendix 6 of this handbook.

There is a $30.00 calendar year limit per recipient per provider for podiatry service copayments. For clinics with a billing provider number, the limitation is calculated per recipient per billing provider number instead of per recipient per performing provider number. For individual podiatrists billing under their own provider number and not under a clinic provider number, the limitation is per recipient per podiatrist.

Providers are reminded of the following copayment exemptions:

ARCHIVAL USE ONLY RecipientInformation

? Emergency services. ? Services covered by Wisconsin Medicaid

Recipient Eligibility

Refer to the Online Handbook WisconsinMedicaidprovidersshouldverify

recipient eligibility and identify any limitations to

for current policy the recipient's coverage before providing

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

services. Refer to the All-Provider Handbook

residents.

for detailed information on accessing the

? Services provided to recipients under 18

Eligibility Verification System and eligibility for

years of age.

Wisconsin Medicaid. For telephone numbers regarding recipient eligibility, refer to the Important Telephone Numbers page at the beginning of this handbook.

The copayment must be collected from the recipient by the service provider. Applicable copayment amounts are automatically deducted by Wisconsin Medicaid from

Copayment

allowable payments.

Except as noted below, all recipients are responsible for paying part of the costs involved in obtaining podiatry services.

5 Podiatry Services Handbook u May 2003

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