BadgerCare Plus and Wisconsin Medicaid define "new patient" as a patient who is new to the provider and whose medical and administrative records need to be established. This is interpreted to be a new patient to either the vision care provider or to the group practice. One new patient procedure per member, per rendering or billing provider, per three years is allowed.
Only one office visit is allowed per DOS for a new or established patient, per rendering provider.
General and special ophthalmological services procedure codes for new and established patients (procedure codes 92002, 92004, 92012, and 92014) should be used when billing other ophthalmological services including refractions.
The E&M codes generally should not be used when billing for ophthalmological services. E&M services (procedure codes 99202–99205 and 99211–99215 and HCPCS procedure code G2212) are not covered when they are directly related to a covered ophthalmological service. However, when the E&M service is provided in response to a different diagnosis, the E&M service may be covered on the same DOS as the covered ophthalmological code.
BadgerCare Plus and Wisconsin Medicaid have adopted the federal CMS 1995, 1997, and 2021 "Documentation Guidelines for Evaluation and Management Services," in combination with BadgerCare Plus and Medicaid policy for E&M services. Providers are required to present documentation upon request from the Wisconsin Department of Health Services indicating which of the guidelines or BadgerCare Plus policies were utilized for the E&M procedure code that was billed. For E&M outpatient office visits (CPT procedure codes 99202–99205 and 99211–99215 and HCPCS procedure code G2212), only the 2021 documentation guidelines apply.
When using the CMS 2021 documentation guidelines for procedure codes 99202–99205 and 99211–99215, providers are required to retain in their records whether they are billing using MDM or time. Based on CPT guidelines, if providers bill for time, total time must be reflected in the documentation.
The documentation in the member's medical record for each service must justify the level of the E&M code billed. Providers may access the CMS documentation guidelines on the CMS website. BadgerCare Plus and Medicaid policy information can be found in service-specific areas of the Online Handbook.