For Dates of Service Before January 1, 2023

Critical Care and Prolonged Services

Wisconsin Medicaid reimburses up to four hours per DOS for critical care (CPT procedure codes 99291–99292) and prolonged services (CPT procedure codes 99354–99357 and 99360).

To request reimbursement for time in excess of four hours per DOS, providers should submit an Adjustment/Reconsideration Request form for an allowed claim. Supporting clinical documentation (for example, a history and physical exam report or a medical progress note) that identifies why reimbursement for services in excess of four hours is requested must be included.

Wisconsin Medicaid only reimburses prolonged care services (CPT procedure codes 99354–99357 and 99360) if there is face-to-face contact between the provider and the member. Prolonged care services without face-to-face contact (CPT codes 99358 and 99359) are not covered.

Ambulance Services

Critical care services provided by physicians in an air or ground ambulance are reimbursed under either critical care or prolonged care procedure codes. Claims for services provided in an ambulance must be submitted on a paper claim with a copy of the physician's clinical record attached.

Wisconsin Medicaid does not reimburse physicians for supervising from the home base of a hospital's emergency transportation unit or for supervising in the ambulance.