Information for Dates of Service Before October 1, 2015
Screenings
Medicaid-allowable screening procedure codes are identified in the allowable procedure codes list for physician services providers. The following are general principles for coverage of screening and diagnostic procedures:
- Wisconsin Medicaid reimburses both screening and diagnostic tests and procedures under the appropriate procedure codes.
- Reimbursement for office visits is included with the reimbursement for surgical procedures, whether diagnostic or screening (e.g., colonoscopy, flexible sigmoidoscopy). Providers should not submit claims for office visits when performing surgical procedures on the same DOS.
- Laboratory and radiology screening and diagnostic procedures are separately reimbursable when submitted with an office visit procedure code on the same DOS.
Screening Procedures Coverage
Providers should indicate screening procedure codes when submitting claims in the following instances:
- For routine tests or procedures performed to identify members at increased risk for diseases.
- When a member is asymptomatic or does not have a personal history of the disease (or related conditions) for which the screening test is being performed.
Wisconsin Medicaid does not limit the frequency, age criteria, or reasons for screening; rather, this is left to best medical judgment based on standard medical practice and the patient's individual circumstances.
Claims for screenings must have the diagnosis code field completed (e.g., a preventive code). For example, a claim for a glaucoma screening could indicate ICD-9-CM diagnosis code V80.1 (Special screening for neurological, eye, and ear diseases; Glaucoma).
Diagnostic Procedures
Providers should indicate diagnostic procedure codes when submitting claims in the following instances:
- There are symptoms or other indications of a medical problem.
- To confirm a previous diagnosis.
- There is a personal history of a medical problem or related condition.
- During a screening, a problem or medical condition is found and a biopsy or other sample is taken for further study and analysis.
Service-Specific Information
The following information gives details about each kind of screening and/or when to request reimbursement for diagnostic services. Refer to CPT for diagnostic procedure codes.
Breast Cancer - Mammography
Wisconsin Medicaid does not have limitations on the frequency of mammography. Providers may be reimbursed for both a screening mammography and a diagnostic mammography for the same patient on the same DOS if they are performed as separate films. Reasons for the separate procedures must be documented in the member's medical record.
Colorectal Cancer
Providers may submit claims for a variety of colorectal cancer screening or diagnostic tests, including laboratory tests, flexible sigmoidoscopy, proctosigmoidoscopy, barium enema, and colonoscopy. Providers should indicate the HCPCS or CPT procedure code that best reflects the nature of the procedure. If abnormalities (e.g., polyps) are found during a screening colonoscopy or sigmoidoscopy and biopsies taken or other coverage criteria are met (e.g., personal history of colon cancer), then the CPT diagnostic procedure code should be indicated.
Screening CT colonography will be covered with PA under the following circumstances:
- Once every five years for members 50 years of age or older who are unable, due to an accompanying medical condition, to undergo screening optical colonoscopy or who have failed optical colonoscopy.
- Once every five years for members younger than 50 years of age who are unable, due to an accompanying medical condition, to undergo screening optical colonoscopy or have had a failed optical colonoscopy and are at increased risk for colorectal cancer or polyps due to one of the following:
- Strong family history of colorectal cancer or polyps in a first-degree relative younger than 60 years of age.
- Two or more first-degree relatives of any age with a history of colorectal cancer.
- Known family history of colorectal cancer syndromes such as familial adenomatous polyposis (FAP) or hereditary nonpolyposis colon cancer (HNPCC).
The following are accompanying medical conditions:
- An optical colonoscopy is incomplete due to an inability to pass the colonoscope because of an obstructing rectal or colon lesion, stricture, scarring from previous surgery, tortuosity, redundancy, or severe diverticulitis.
- If the member is receiving chronic anti-coagulation that cannot be interrupted.
- If the member is unable to tolerate optical colonoscopy, associated sedation, or specified bowel prep due to cardiac, pulmonary, neuromuscular, or metabolic comorbidities.
Glaucoma
Wisconsin Medicaid reimburses for glaucoma screening examinations when they are performed by or under the direct supervision of an ophthalmologist or optometrist. If a member has a previous history of glaucoma, indicate the CPT diagnostic procedure code when submitting a claim for services. In either case, Wisconsin Medicaid will not separately reimburse a provider for a glaucoma screening if an ophthalmological exam is provided to a member on the same DOS. Glaucoma screening and diagnostic examinations are included in the reimbursement for the ophthalmological exam.
Pap Smears
Wisconsin Medicaid covers both screening and diagnostic Pap smears. Providers may receive reimbursement for both a screening and diagnostic Pap smear for the same DOS if abnormalities are found during a screening procedure and a subsequent diagnostic procedure is done as a follow-up. Providers are required to document this in the member's medical record.
Pelvic and Breast Exams
Wisconsin Medicaid reimburses for a screening pelvic and breast exam if it is the only procedure performed on that DOS. A pelvic and breast exam (HCPCS procedure code G0101) performed during a routine physical examination or a problem-oriented office visit is not separately reimbursable but is included in the reimbursement for the physical examination or office visit. When using an E&M office visit procedure code, the time and resources for the pelvic and breast exam should be factored into the determination of the appropriate level for the office visit.
Prostate Cancer
The following tests and procedures provided to an individual for the early detection and monitoring of prostate cancer and related conditions are covered:
- Screening DRE — This test is a routine clinical examination of an asymptomatic individual's prostate for nodules or other abnormalities of the prostate.
- Screening PSA Blood Test — This test detects the marker for adenocarcinoma of the prostate.
- Diagnostic PSA Blood Test — This test is used when there is a diagnosis or history of prostate cancer or other prostate conditions for which the test is a reliable indicator.
Reimbursement for a DRE is included in the reimbursement for a covered E&M or preventive medical examination when the services are furnished to a member on the same day. If the DRE is the only service provided, the applicable procedure code may be reimbursed. The screening and diagnostic PSA tests are separately reimbursable when performed on the same DOS as an E&M or preventive medical exam.