|Program Name: ||BadgerCare Plus and Medicaid ||Handbook Area: ||Nurse Midwife |
Covered and Noncovered Services : Covered Services and Requirements
Nurse midwives should use the Nurse Midwife service area of the Online Handbook in conjunction with the Physician service area. The Nurse Midwife service area includes the following limited information that applies to fee-for-service Medicaid-enrolled nurse midwives:
- Enrollment, including protocols and collaborative agreements
- Covered services, including obstetric services
- Newborn reporting and screenings
The Physician service area includes information about the following:
- E&M services
- Laboratory services
- Medicine services
- Radiology services
- Surgery services
Nurse midwives are limited to providing the following categories of covered services:
- Family planning services
- Laboratory services
- Obstetric services
- Office and outpatient visits
- TB-related services
The practice of nurse midwifery means "the management of women's health care, pregnancy, childbirth, postpartum care for newborns, family planning, and gynecological services consistent with the standards of practice of the American College of Nurse-Midwives and the education, training, and experience of the nurse-midwife" (Wis. Stats. Board of Nursing § 441.15).
All nurse midwife services must be fully documented in the member's medical record and available for inspection or review by the Wisconsin DHS auditors.
ForwardHealth covers CTPs in limited circumstances where evidence of efficacy is strong. ForwardHealth only covers CTPs for wound treatment for members with neuropathic diabetic foot ulcers, non-infected venous leg ulcers, or members who are undergoing breast reconstruction surgery following a breast cancer diagnosis.
CTPs are biological or biosynthetic products used to assist in the healing of open wounds. Evidence of the efficacy of this treatment varies significantly by both the patient treated and the product being used.
Product Coverage Review Policy
Currently, limited research is available on the effectiveness of CTPs. ForwardHealth uses
Hayes ratings to determine the appropriateness and effectiveness of medical products such as CTPs.
Certificate of Need for Transportation
ForwardHealth covers SMV services if the transportation is to and from a facility where the member receives Medicaid-covered services and the member meets the criteria for SMV services. The following are criteria for SMV services:
- A member must be indefinitely disabled, legally blind, or temporarily disabled.
- A member must have a medical condition that contraindicates safe travel by common carrier such as bus, taxi, or private vehicle.
If a member meets the criteria, a physician, physician assistant, nurse practitioner, or nurse midwife should complete a Certification of Need for Specialized Medical Vehicle Transportation form.
Inconvenience or lack of timely transportation are not valid justifications for the use of SMV transportation. The presence of a disability does not by itself justify SMV transportation.
The medical provider gives a copy of the completed form to the member who then gives the form to the SMV provider. The medical provider does not need to keep a copy of the completed form on file, but they are required to document the medical condition necessitating SMV transportation in the member's medical record.
Physicians are required to complete a new Certification of Need for Specialized Medical Vehicle Transportation form upon expiration. For members who are indefinitely disabled, the form is valid for three years (36 months) from the date the medical provider signed the form. For members who are temporarily disabled, the form is valid for the period indicated on the form, which must not exceed 90 days from the date the medical provider signed the form.
Medical providers must not complete the forms retroactively for SMV providers or members.
Providers may not charge members for completing the Certification of Need for Specialized Medical Vehicle Transportation form. Wisconsin Medicaid will reimburse providers at the lowest level E&M CPT procedure code if the member is in the office when the form is completed and no other medical service is provided.
Definition of Covered Services
A covered service is a service, item, or supply for which reimbursement is available when all program requirements are met. Wis. Admin. Code § DHS 101.03(35) and ch. DHS 107 contain more information about covered services.
Certain program requirements and reimbursement procedures are modified in emergency situations. Emergency services are defined in Wis. Admin. Code § DHS 101.03(52), as "those services that are necessary to prevent the death or serious impairment of the health of the individual." Emergency services are not reimbursed unless they are covered services.
Additional definitions and procedures for emergencies exist in other situations, such as dental and mental health.
Program requirements and reimbursement procedures may be modified in the following ways:
- PA or other program requirements may be waived in emergency situations.
- Non-U.S. citizens may be eligible for covered services in emergency situations.
Evaluation and Management Services
It is not medically necessary or appropriate to bill a higher level of E&M service when a lower level of service is warranted.
Wisconsin Medicaid reimburses only for services that are medically necessary as defined under Wis. Admin. Code § DHS 101.03(96m). Wisconsin Medicaid may deny or recoup payment if a service fails to meet Medicaid medical necessity requirements.
Member Payment for Covered Services
Under state and federal laws, a Medicaid-enrolled provider may not collect payment from a member, or authorized person acting on behalf of the member, for covered services even if the services are covered but do not meet program requirements. Denial of a claim by ForwardHealth does not necessarily render a member liable. However, a covered service for which PA was denied is treated as a noncovered service. (If a member chooses to receive an originally requested service instead of the service approved on a modified PA request, it is also treated as a noncovered service.) If a member requests a covered service for which PA was denied (or modified), the provider may collect payment from the member if certain conditions are met.
If a provider collects payment from a member, or an authorized person acting on behalf of the member, for a covered service, the provider may be subject to program sanctions including termination of Medicaid enrollment.
Not Otherwise Classified Procedure Codes
Providers who indicate procedure codes such as J3490 (Unclassified drugs), J3590 (Unclassified biologics), or J9999 (Not otherwise classified, antineoplastic drugs) on claims for NOC drugs must also indicate the following on the claim:
- The NDC of the drug dispensed
- The name of the drug
- The quantity billed
- The unit of issue (i.e., F2, gr, me, ml, un)
If this information is not included on the claim or if there is a more specific HCPCS procedure code for the drug, the claim will be denied. Compound drugs that do not include a drug approved by the FDA will be denied.
Providers are required to comply with the requirements of the federal DRA of 2005 and submit NDCs with HCPCS and CPT procedure codes for provider-administered drugs. Section 1927(a)(7)(C) of the Social Security Act requires NDCs to be indicated on all claims submitted to ForwardHealth for covered outpatient drugs, including Medicare crossover claims.
For a covered service to meet program requirements, the service must be provided by a qualified Medicaid-enrolled provider to an enrolled member. In addition, the service must meet all applicable program requirements, including, but not limited to, medical necessity, PA, claims submission, prescription, and documentation requirements.
A provider-administered drug is either an oral, injectable, intravenous, or inhaled drug administered by a physician or a designee of the physician (e.g., nurse, nurse practitioner, physician assistant).
Providers may refer to the maximum allowable fee schedules for the most current HCPCS and CPT procedure codes for provider-administered drugs and reimbursement rates.
Provider-administered drugs carve-out policy is defined to include the following procedure codes:
- Drug-related "J" codes
- Drug-related "Q" codes
- Certain drug-related "S" codes
The Provider-Administered Drugs Carve-Out Procedure Codes table indicates the status of procedure codes considered under the provider-administered drugs carve-out policy. This table provides information on Medicaid and BadgerCare Plus coverage status as well as carve-out status based on POS.
Note: The table will be revised in accordance with national annual and quarterly HCPCS code updates.
For members enrolled in BadgerCare Plus HMOs, Medicaid SSI HMOs, and most special managed care programs, claims for these services should be submitted to BadgerCare Plus and Medicaid fee-for-service.
All fee-for-service policies and procedures related to provider-administered drugs, including copayment, cost sharing, diagnosis restriction, PA, and pricing policies, apply to claims submitted to fee-for-service for members enrolled in an MCO.
Provider-administered drugs and related services for members enrolled in PACE are provided and reimbursed by the special managed care program.
Note: For Family Care Partnership members who are not enrolled in Medicare (Medicaid-only members), outpatient drugs (excluding diabetic supplies), provider-administered drugs, compound drugs (including parenteral nutrition), and any other drugs requiring drug utilization review are covered by fee-for-service Medicaid. All fee-for-service policies, procedures, and requirements apply for pharmacy services provided to Medicaid-only Family Care Partnership members. Dual eligibles (enrolled in Medicare and Medicaid) receive their outpatient drugs through their Medicare Part D plans. However, if the member's Part D plan does not cover the outpatient drug, these dually eligible members may access certain Medicaid outpatient drugs that are excluded or otherwise restricted from Medicare coverage through fee-for-service Medicaid. For these drugs, fee-for-service policies would apply.
Obtaining Provider-Administered Drugs
To ensure the content and integrity of the drugs administered to members, prescribers are required to obtain all drugs that will be administered in their offices. Prescribers may obtain a provider-administered drug from a pharmacy provider if the drug is delivered directly from the pharmacy to the prescriber's office. Prescribers may also obtain a drug to be administered in the prescriber's office from a drug wholesaler or direct purchase. Pharmacy providers should not dispense a drug to a member if the drug will be administered in the prescriber's office.
Services That Do Not Meet Program Requirements
As stated in Wis. Admin. Code § DHS 107.02(2), BadgerCare Plus and Wisconsin Medicaid may deny or recoup payment for covered services that fail to meet program requirements.
Examples of covered services that do not meet program requirements include the following:
- Services for which records or other documentation were not prepared or maintained
- Services for which the provider fails to meet any or all of the requirements of Wis. Admin. Code § DHS 106.03, including, but not limited to, the requirements regarding timely submission of claims
- Services that fail to comply with requirements or state and federal statutes, rules, and regulations
- Services that the Wisconsin DHS, the PRO review process, or BadgerCare Plus determines to be inappropriate, in excess of accepted standards of reasonableness or less costly alternative services, or of excessive frequency or duration
- Services provided by a provider who fails or refuses to meet and maintain any of the enrollment requirements under Wis. Admin. Code ch. DHS 105
- Services provided by a provider who fails or refuses to provide access to records
- Services provided inconsistent with an intermediate sanction or sanctions imposed by DHS
Sleep Medicine Testing
Sleep medicine testing involves six or more hours of continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep with physician review, interpretation, and reporting. Polysomnography is distinguished from facility-based sleep studies and home-based sleep studies by the inclusion of sleep staging. Type IV sleep testing devices are not covered by ForwardHealth.
Facility-Based Sleep Studies and Polysomnography
ForwardHealth covers facility-based sleep studies and polysomnography when ordered by the member's physician and performed in a sleep laboratory, an outpatient hospital, or an independent diagnostic testing facility for sleep disorders. Physicians interpretreting facility-based sleep studies and polysomnograms are required to have board certification in sleep medicine in order for the services to be reimbursed.
A list of allowable facility-based sleep study and polysomnography CPT procedure codes is available. Facility-based sleep study and polysomnography procedures do not require PA.
Home-Based Sleep Studies
ForwardHealth covers unattended home-based sleep studies when ordered by the member's physician. Physicians interpreting home-based sleep studies are required to have board certification in sleep medicine in order for the services to be reimbursed.
A list of allowable home-based sleep study HCPCS procedure codes is available. Home-based sleep studies do not require PA.
Coverage Limitations for Sleep Medicine Testing
ForwardHealth does not cover the following:
- Unattended sleep studies for the diagnosis of obstructive sleep apnea in members with significant comorbid medical conditions that may affect the accuracy of the unattended sleep study, including, but not limited to, other sleep disorders
- Attendance of a nurse, home health aid, or personal care worker during a home-based sleep study
- Any parts of a home-based sleep study peformed by a DME provider including, but not limited to, the delivery and/or pick up of the device
- Home-based sleep studies for children (ages 18 and younger)
- Abbreviated daytime sleep study (PAP-NAP) or daytime nap polysomnography
Information is available for DOS before January 1, 2021.
ForwardHealth allows certain covered services to be provided via telehealth (also known as "telemedicine"). Telehealth enables a provider who is located at a distant site to render the service remotely to a member located at an originating site using a combination of interactive video, audio, and externally acquired images through a networking environment.
There is no restriction on the location of a distant site provider. The following types of providers may be reimbursed for providing telehealth services at a distant site:
- Individual mental health and substance abuse practitioners not in a facility certified by the DQA
- Nurse midwives
- Nurse practitioners
- Ph.D. psychologists
- Physician assistants
- Professionals providing services in mental health or substance abuse programs certified by the DQA
Allowable Originating Sites
ForwardHealth allows coverage of telehealth for any originating site. However, only the following originating sites are eligible for a facility fee reimbursement:
- Hospitals, including emergency departments
- Skilled nursing facility
Requirements and Restrictions
Services provided via telehealth must be of sufficient audio and visual fidelity and clarity as to be functionally equivalent to a face-to-face visit where both the rendering provider and member are in the same physical location. Both the distant and originating sites must have the requisite equipment and staffing necessary to provide the telehealth service.
Coverage of a service provided via telehealth is subject to the same restrictions as when the service is provided face-to-face (for example, allowable providers, multiple service limitations, PA).
Providers are reminded that HIPAA confidentiality requirements apply to telehealth services. When a covered entity or provider utilizes a telehealth service that involves PHI, the entity or provider will need to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to PHI confidentiality, integrity, and availability. Each entity or provider must assess what are reasonable and appropriate security measures for their situation.
Note: Providers may not require the use of telehealth as a condition of treating a member. Providers must develop and implement their own methods of informed consent to verify that a member agrees to receive services via telehealth. These methods must comply with all federal and state regulations and guidelines.
The following are not covered as telehealth services:
- Store and forward services (defined as the asynchronous transmission of medical information to be reviewed at a later time by a provider at a distant site)
- Services that are not covered when delivered face-to-face
Claims Submission and Reimbursement for Distant Site Providers
Claims for services provided via telehealth by distant site providers must be billed with the same procedure code as would be used for a face-to-face encounter along with HCPCS modifier GT (via interactive audio and video telecommunication systems).
Claims must also include POS code 02 (Telehealth: the location where health services and health-related services are provided or received through telehealth telecommunication technology). ForwardHealth reimburses the service rendered by distant site providers at the same rate as when the service is provided face-to-face.
Claims for services provided via telehealth by distant site ancillary providers should continue to be submitted under the supervising physician's NPI using the lowest appropriate level office or outpatient visit procedure code or other appropriate CPT code for the service performed. These services must be provided under the direct on-site supervision of a physician who is located at the same physical site as the ancillary provider and must be documented in the same manner as services that are provided face to face.
Pediatric and Health Professional Shortage Area-Eligible Services
Claims for services provided via telehealth by distant site providers may additionally qualify for pediatric (services for members 18 years of age and under) or HPSA-enhanced reimbursement. Pediatric and HPSA-eligible providers are required to indicate POS code 02, along with modifier GT and the applicable pediatric or HPSA modifier, when submitting claims that qualify for enhanced reimbursement.
Claims Submission and Reimbursement for Originating Site Facility Fee
In addition to reimbursement to the distant site provider, ForwardHealth reimburses an originating site facility fee for the staff and equipment at the originating site requisite to provide a service via telehealth. Eligible providers who serve as the originating site should bill the facility fee with HCPCS procedure code Q3014 (Telehealth originating site facility fee). HCPCS modifier GT should not be included with procedure code Q3014.
Eligible providers who bill on a professional claim form should bill Q3014 with a POS code that represents where the member is located during the service. The POS must be a ForwardHealth-allowable originating site for procedure code Q3014 in order to be reimbursed for the originating site fee. The originating site fee is reimbursed based on a maximum allowable fee.
Eligible providers who bill on an institutional claim form should bill Q3014 as a separate line item with the appropriate revenue code. ForwardHealth will reimburse these providers for the facility fee based on the provider's standard reimbursement methodology.
All services provided via telehealth must be thoroughly documented in the member's medical record in the same manner as services provided face-to-face. As a reminder, documentation for originating sites must support the member's presence in order to submit a claim for the originating site facility fee. In addition, if the originating site provides and bills for services in addition to the originating site facility fee, documentation in the member's medical record should distinguish between the unique services provided.
Telestroke, also known as stroke telemedicine, is a delivery mechanism of telehealth services that aims to improve access to recommended stroke treatment.
ForwardHealth allows providers to be reimbursed for telestroke services. Telestroke services typically consist of the member and emergency providers at an originating site consulting with a specialist located at a distant site.
Claims Submission for Telestroke Services
Providers are required to use CPT consultation and E&M procedure codes when billing telestroke services. Telestroke services are subject to the same enrollment policy, coverage policy, and billing policy as telehealth services. All other services rendered by the provider at the originating site, and by any providers to which the member is transferred, should be billed in the same manner as visits or admissions that do not involve telehealth services.
Originating sites that have established contractual relationships for telestroke services may bill as they would for any other contracted professional services for both the professional service claim on behalf of the distant site provider and the originating site fee.
Additional Policy for Certain Types of Providers
ForwardHealth policy for services provided via telehealth by out-of-state providers is the same as ForwardHealth policy for services provided face-to-face by out-of-state providers. Out-of-state providers who do not have border status enrollment with Wisconsin Medicaid are required to obtain PA before providing services via telehealth to BadgerCare Plus or Medicaid members.
Note: Wisconsin Medicaid is prohibited from paying providers located outside of the United States and its territories, including the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.
Federally Qualified Health Centers and Rural Health Clinics
For the purpose of this Online Handbook topic, FQHC refers to Tribal and Out-of-State FQHCs. This topic does not apply to Community Health Centers subject to PPS reimbursement.
FQHCs and RHCs may serve as originating site and distant site providers for telehealth services.
FQHCs and RHCs may report services provided via telehealth on the cost settlement report when the FQHC or RHC served as the distant site and the member is an established patient of the FQHC or RHC at the time of the telehealth service.
Services billed with modifier GT (modifier indicating telehealth) will be considered under the PPS reimbursement method for non-tribal FQHCs. Billing HCPCS procedure code T1015 (Clinic visit/encounter, all-inclusive) with a telehealth procedure code will result in a PPS rate for fee-for-service encounters.
The originating site facility fee is not a FQHC or RHC reportable encounter on the cost report. Any reimbursement for the originating site facility fee must be reported as a deductive value on the cost report.
ForwardHealth only covers telehealth delivery of individual services. For those procedure codes that can be used for either individual or group services, providers may not submit claims for telehealth delivery of group services. Allowable providers may be reimbursed, as appropriate, for the following services (and applicable procedure codes) provided through telehealth.
Note: The use of E&M codes is subject to E&M documentation guidelines.
|Type of Service
|Adult Mental Health Day Treatment Services
||H2012 (for individual services only)
||92517, 92518, 92519, 92550, 92587, 92588
|Child/Adolescent Day Treatment Services (HealthCheck "Other Services")
||H2012 (for individual services only)
|Community Support Program Services
||H0039 (for individual services only)
|Comprehensive Community Services
||H2017 (for individual services only)
|Crisis Intervention Services
|End-Stage Renal Disease-Related Services
||9095190952, 9095490958, 9096090961, 9096790970
||Health and Behavior Assessment/Intervention
||96156, 9615896159, 96167, 9617096171
|Initial Inpatient Consultations
|Nursing Facility Service Assessments
|Office or Other Outpatient Services
||9920299205, 9921199215, G2212*
|Office or Other Outpatient Consultations
|Outpatient Mental Health Services (Evaluation, Psychotherapy)
||90785, 9079190792, 9083290834, 9083690840, 9084590847, 90849, 90875, 90876, 90887
|Outpatient Substance Abuse Services
||H0022, H0047, T1006
|Phone Services, Qualified Health Professional
|Substance Abuse Day Treatment
||H2012 (for individual services only)
* Telehealth services that are medical in nature and would otherwise be coded as an office visit or consultation evaluation and management visit are covered for members residing in a skilled nursing facility. Some Nursing Facility Service Assessments are not covered as telehealth services (for example, 9930499318). Domiciliary, Rest Home, or Custodial Care Services and Oversight Services (procedure codes 9932499340) are not allowable as telehealth services.