Covered and Noncovered Services : Medicine Services

Physician-Administered Drugs

Procedure codes for Medicaid-covered physician-administered drugs are listed in the physician services maximum allowable fee schedule. Providers should use the appropriate fee schedule in conjunction with the most recent HCPCS coding book for descriptions.

Diagnosis Restrictions for Physician-Administered Drugs

Diagnosis restrictions that apply to NDCs also apply to corresponding HCPCS codes when billed as physician-administered drugs. Wisconsin Medicaid requires a valid and acceptable ICD diagnosis code on claims for selected physician-administered drugs. A ForwardHealth-allowed diagnosis code must be indicated on claims (and PA requests when applicable) for diagnosis-restricted physician-administered drugs.

The Diagnosis Code-Restricted Physician-Administered Drugs data table contains information about diagnosis-restricted physician-administered drugs. For each drug, the corresponding HCPCS procedure code, ICD diagnosis code(s), and disease description(s) are listed. If the member's diagnosis is not an allowable diagnosis for the code listed on the Diagnosis Code-Restricted Physician-Administered Drugs data table, prescribers are required to obtain PA.

If a prescriber orders a physician-administered drug with a diagnosis outside the ForwardHealth-allowed diagnosis for a drug, the prescriber must submit peer-reviewed medical literature to support the proven efficacy and safety of the requested use of the drug. The prescriber also must include documentation of previous treatments and detailed reasons why other covered drug treatments were discontinued or not used. Medical records should be provided as necessary to support the PA request.

PA Requirements

Prescribers are required to obtain PA for certain Medicaid-allowable drugs and physician-administered drugs that are not provided with an allowable diagnosis code. Prescribers are required to use the PA/PAD form along with the PA/RF to request PA.

Only the diagnosis codes included in the diagnosis code-restricted physician-administered drugs data table are reimbursable without PA.

Unclassified Drugs

Providers should not submit claims with HCPCS procedure code J3490 when there is another procedure code that better describes the drug. Claims with J3490 will be denied if there is a more specific code that may be used.

Procedure code J3490 requires PA only when the drug may also be used as a fertility drug.

To be reimbursed for an unclassified drug that does not require PA or a HCPCS code that does not have a maximum allowable fee listed in the fee schedule for physicians, providers are required to submit a paper 1500 Health Insurance Claim Form and attach the following information:

• Name of drug
• NDC
• Dosage
• Quantity (for example, vials, milliliters, milligrams)