For Dates of Service Before January 1, 2022
Preventive Medicine Services
Wisconsin Medicaid reimburses family planning clinic providers for preventive medicine services provided to eligible members.
Covered services include initial preventive medicine E&M of new patients (Physician's CPT 99384-99387) and reevaluation and management of established patients (CPT 99394-99397), including:
- A comprehensive history
- A comprehensive examination
- Counseling/anticipatory guidance/risk factor reduction interventions
- The ordering of appropriate laboratory/diagnostic procedures
Prescriptions
Prescribing Contraceptive Methods
The prescribing of contraceptive methods is a covered service with reimbursement included in the reimbursement for the office visit. The contraceptive method selected should be the choice of the member, based on full information, except when in conflict with sound medical practice.
The following covered services may be prescribed:
- Natural family planning
- Contraceptive implants
- Diaphragms
- IUDs
- Contraceptive pills (Procedure code S4993 [Contraceptive pills for birth control] should not be used if contraceptives are included in the office visit.)
- Emergency contraception
Prescribing Breast Pumps
Wisconsin Medicaid reimburses for the prescribing of breast pumps as part of an E&M office visit. The following three types of breast pumps are covered:
- Manual or pedal-powered with single- or double-pumping kit
- Electric, hospital grade, including single- or double-pumping kit
- Powered/electric, portable with intermittent suction, including single- or double-pumping kit
Family planning clinic providers may prescribe breast pumps to members who meet all of the following criteria:
- The member has recently delivered a baby and a physician has ordered or recommended mother's breast milk for the infant.
- Documentation indicates there is the potential for adequate milk production.
- Documentation shows there is a long-term need and planned use of the breast pump to obtain a milk supply for the infant.
- The member is capable of being trained to use the breast pump, as indicated by the physician or provider.
- Current or expected physical separation of mother and infant (e.g., illness, hospitalization, or work) would make breast-feeding difficult, or there is difficulty with "latch on" due to physical, emotional, or developmental problems of the mother or infant.
The optional Breast Pump Order form may be completed by the prescribing family planning clinic provider.
Family planning clinic physicians or nurse practitioners may prescribe breast pumps for members, which can then be obtained through a Medicaid-enrolled DME provider or pharmacy. Wisconsin Medicaid does not reimburse family planning clinics for supplying breast pumps, unless they are also Medicaid-enrolled as a DME provider or pharmacy.
Counseling Services
Counseling services in the clinic are covered and may be performed or supervised by a physician, registered nurse, or nurse practitioner, according to Wis. Admin. Code § DHS 107.21(1)(d). Counseling services may be provided as a result of a member's request or by indications from exam procedures and history. Wisconsin Medicaid denies reimbursement for counseling services not identified as part of an E&M service (Physicians' CPT counseling codes [99401-99404] are not recognized by Wisconsin Medicaid).
According to Wis. Admin. Code § DHS 107.21(1)(d), covered counseling services are limited to the following areas:
- Instruction on reproductive anatomy and physiology.
- Overview of available methods of contraception, including natural family planning. An explanation of the medical ramifications and effectiveness of each must be provided.
- Sexually transmitted disease information.
- Information about sterility and a full explanation of sterilization procedures, including:
- Associated discomfort
- Risks
- Benefits
- Irreversibility
- Information about genetics and a full explanation of procedures utilized in genetic assessment, including information regarding the medical ramifications for unborn children and planning of care for unborn children with either diagnosed or possible genetic abnormalities.
- Information regarding teratologic evaluations.
- Information and education regarding pregnancies requested by the member, including prenatal counseling and referral.
- Information regarding alcohol abuse, sexual abuse, and domestic violence.