Covered and Noncovered Services : Codes

Ambulance Disposable Medical Supplies and Services

The following table lists allowable HCPCS codes for DMS and services that may or may not be billed separately for ambulance services. For both DMS and ambulance services with no listed national HCPCS procedure codes, providers may use HCPCS procedure code A0999 (Unlisted ambulance service).

^* Includes additional charges for services provided during nights, weekends, or holidays.

^** Includes charges for carrying a member with a contagious disease.

^* Providers should use procedure code A0999 for any DMS or service not listed.

Diagnosis Codes for Ambulance Services

All codes indicated on submissions to ForwardHealth are required to be valid codes.

Ambulance providers may use the ICD diagnosis code R69 (Illness, unspecified) if a valid diagnosis is unknown.

Modifiers

BadgerCare Plus accepts nationally recognized modifiers on claims and other forms, when applicable. The following table lists allowable modifiers for ambulance services providers.

Note: Use all of these modifiers on claims and not on PA requests.

^* These single-letter modifiers are used in combination on the claim form to indicate the origin and destination of the ambulance trip. The first letter indicates the transport's place of origin; the second letter indicates the destination.

Information is available for DOS before October 1, 2023.

Place of Service Codes

Ambulance providers should use the appropriate POS code designating the destination of the transport. The following table lists the allowable POS codes that providers are required to use when submitting claims and prior authorization requests for ambulance services.

Procedure Codes and Modifiers

The following table lists allowable HCPCS codes and modifiers for ambulance services. These codes are updated on a quarterly basis. Consult the maximum allowable fee schedule or call Provider Services for the most current procedure codes and allowable modifier combinations.

¹ BadgerCare Plus assigns BLS status to all land ambulance providers with a Wisconsin DHS ambulance service provider license at the basic level.

² BadgerCare Plus assigns ALS status to all land ambulance providers with a DHS ambulance service provider license at the intermediate or paramedic level.

³ A0425 will only be reimbursed by BadgerCare Plus and Wisconsin Medicaid when it appears on a Medicare crossover claim for a dual eligible or when it is used to bill for NEMT provided by an ambulance to a member who is not eligible to receive NEMT through the NEMT manager contracted with DHS.

⁴ This code may be used for both DMS and ambulance services if a more specific code is unavailable.

Unlisted Procedure Codes

According to the HCPCS codebook, if a service is provided that is not accurately described by other HCPCS CPT procedure codes, the service should be reported using an unlisted procedure code.

Before considering using an unlisted, or NOC, procedure code, a provider should determine if there is another more specific code that could be indicated to describe the procedure or service being performed/provided. If there is no more specific code available, the provider is required to submit the appropriate documentation, which could include a PA request, to justify use of the unlisted procedure code and to describe the procedure or service rendered. Submitting the proper documentation, which could include a PA request, may result in more timely claims processing.

Unlisted procedure codes should not be used to request adjusted reimbursement for a procedure for which there is a more specific code available.

Unlisted Codes That Do Not Require Prior Authorization or Additional Supporting Documentation

For a limited group of unlisted procedure codes, ForwardHealth has established specific policies for their use and associated reimbursement. These codes do not require PA or additional documentation to be submitted with the claim. Providers should refer to their service-specific area of the Online Handbook on the ForwardHealth Portal for details about these unlisted codes.

For most unlisted codes, ForwardHealth requires additional documentation.

Unlisted Codes That Require Prior Authorization

Certain unlisted procedure codes require PA. Providers should follow their service-specific PA instructions and documentation requirements for requesting PA. For a list of procedure codes for which ForwardHealth requires PA, refer to the service-specific interactive maximum allowable fee schedule.

In addition to a properly completed PA request, documentation submitted on the service-specific PA attachment or as additional supporting documentation with the PA request should provide the following information:

• Specifically identify or describe the name of the procedure/service being performed or billed under the unlisted code.
• List/justify why other codes are not appropriate.
• Include only relevant documentation.
• Include all required clinical/supporting documentation.

For most situations, once the provider has an approved PA request for the unlisted procedure code, there is no need to submit additional documentation along with the claim.

Unlisted Codes That Do Not Require Prior Authorization

If an unlisted procedure code does not require PA, documentation submitted with the claim to justify use of the unlisted code and to describe the procedure/service rendered must be sufficient to allow ForwardHealth to determine the nature and scope of the procedure and to determine whether or not the procedure is covered and was medically necessary, as defined in Wisconsin Administrative Code.

The documentation submitted should provide the following information related to the unlisted code:

• Specifically identify or describe the name of the procedure/service being performed or billed under the unlisted code.
• List/justify why other codes are not appropriate.
• Include only relevant documentation.

How to Submit Claims and Related Documentation

Claims including an unlisted procedure code and supporting documentation may be submitted to ForwardHealth in the following ways:

• If submitting on paper using the 1500 Health Insurance Claim Form, the provider may do either of the following:
  • Include supporting information/description in Item Number 19 of the claim form.
  • Include supporting documentation on a separate paper attachment. This option should be used if Item Number 19 on the 1500 Health Insurance Claim Form does not allow enough space for the description or when billing multiple unlisted procedure codes. Providers should indicate "See Attachment" in Item Number 19 of the claim form and send the supporting documentation along with the claim form.
• If submitting electronically using DDE on the Portal, PES software, or 837 electronic transactions, the provider may do one of the following:
  • Include supporting documentation in the Notes field. The Notes field is limited to 80 characters.
  • Indicate that supporting documentation will be submitted separately on paper. This option should be used if the Notes field does not allow enough space for the description or when billing multiple unlisted procedure codes. Providers should indicate "See Attachment" in the Notes field of the electronic transaction and submit the supporting documentation on paper.
  • Upload claim attachments via the secure Provider area of the Portal.

Valid Codes Required on Claims

ForwardHealth requires that all codes indicated on claims and PA requests, including diagnosis codes, revenue codes, HCPCS codes, HIPPS codes, and CPT codes be valid codes. Claims received without valid diagnosis codes, revenue codes, and HCPCS, HIPPS, or CPT codes will be denied; PA requests received without valid codes will be returned to the provider. Providers should refer to current national coding and billing manuals for information on valid code sets.

Code Validity

In order for a code to be valid, it must reflect the highest number of required characters as indicated by its national coding and billing manual. If a stakeholder uses a code that is not valid, ForwardHealth will deny the claim or return the PA request, and it will need to be resubmitted with a valid code.

Code Specificity for Diagnosis

All codes allow a high level of detail for a condition. The level of detail for ICD diagnosis codes is expressed as the level of specificity. In order for a code to be valid, it must reflect the highest level of specificity (that is, contain the highest number of characters) required by the code set. For some codes, this could be as few as three characters. If a stakeholder uses an ICD diagnosis code that is not valid (that is, not to the specific number of characters required), ForwardHealth will deny the claim or return the PA request, and it will need to be resubmitted with a valid ICD diagnosis code.