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Nurse Midwife Services Nurse Midwife Services Nurse midwives use this handbook in conjunction with the Physician Services Handbook. Nurse midwives Medicaid certified as nurse practitioners should use the Nurse Practitioner Services Handbook. ARCHIVAL USE ONLY Refer to the Online Handbook for current policy
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Nurse MidwifeServices

Nurse MidwifeServices

Nurse midwives use this

handbook in conjunction with the

Physician Services Handbook.

Nurse midwives Medicaid certified as nurse

practitioners should use the Nurse

Practitioner Services Handbook.

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

IImportant Telephone NumbersWisconsin Medicaid’s Eligibility Verification System (EVS) is available through the following resources to verify checkwriteinformation, claim status, prior authorization status, provider certification, and/or recipient eligibility.

ServiceInformation

available Telephone number Hours

Automated VoiceResponse (AVR)System(Computerized voiceresponse to providerinquiries.)

Checkwrite InformationClaim StatusPrior AuthorizationStatusRecipient Eligibility*

(800) 947-3544(608) 221-4247 (Madison area)

24 hours a day/7 days a week

Personal ComputerSoftwareandMagnetic StripeCard Readers

Recipient Eligibility* Refer to ProviderResources section ofthe All-ProviderHandbook for a list ofcommercial eligibilityverification vendors.

24 hours a day/7 days a week

Provider Services(Correspondentsassist withquestions.)

Checkwrite InformationClaim StatusPrior AuthorizationStatusProvider CertificationRecipient Eligibility*

(800) 947-9627(608) 221-9883 (Madison area)

Policy/Billing and Eligibility:8:30 a.m. - 4:30 p.m. (M, W-F)9:30 a.m. - 4:30 p.m. (T)Pharmacy:8:30 a.m. - 6:00 p.m. (M, W-F)9:30 a.m. - 6:00 p.m. (T)

Direct InformationAccess Line withUpdates forProviders(Dial-Up)(Softwarecommunicationspackage andmodem.)

Checkwrite InformationClaim StatusPrior AuthorizationStatusRecipient Eligibility*

Call (608) 221-4746for more information.

7:00 a.m. - 6:00 p.m. (M-F)

Recipient Services(Recipients orpersons calling onbehalf of recipientsonly.)

Recipient EligibilityMedicaid-CertifiedProvidersGeneral MedicaidInformation

(800) 362-3002(608) 221-5720 (Madison area)

7:30 a.m. - 5:00 p.m. (M-F)

* Please use the information exactly as it appears on the recipient's identification card or the EVS tocomplete the patient information section on claims and other documentation. Recipient eligibilityinformation available through the EVS includes: - Dates of eligibility. - Medicaid managed care program name and telephone number. - Privately purchased managed care or other commercial health insurance coverage. - Medicare coverage. - Lock-In Program status. - Limited benefit information.

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

TTable of Contents

Preface ........................................................................................................................................ 3

General Information ...................................................................................................................... 5

Provider Eligibility and Certification ............................................................................................. 5Nurse Midwife Certification .................................................................................................. 5

Protocols/Collaborative Agreements .......................................................................................... 6Provider Numbers .................................................................................................................... 6

Billing/Performing Provider Number (Issued to Nurse Midwives) ............................................. 7Nurse Midwives Who Submit Claims to Wisconsin Medicaid as Performing Providers

Through a Physician or Clinic .................................................................................... 7Nurse Midwives Who Independently Submit Claims to Wisconsin Medicaid ........................ 7

Group Billing Number (Issued to Clinics) ............................................................................... 7Medicaid-Covered Nurse Midwife Services.................................................................................. 7Reimbursement for Nurse Midwives .......................................................................................... 8

Maximum Allowable Fees .................................................................................................... 8Enhanced Reimbursement .................................................................................................. 8

Obstetric Services ......................................................................................................................... 9

Separate Obstetric Care Components ....................................................................................... 9Antepartum Care ............................................................................................................... 9Delivery ........................................................................................................................... 10Induction of Labor............................................................................................................ 10Postpartum Care.............................................................................................................. 10Delivery and Postpartum Care ........................................................................................... 10

Global Obstetric Care ............................................................................................................. 11Group Claims Submission for Global Obstetric Care ............................................................. 11

Emergency Deliveries ............................................................................................................. 11Home Deliveries .................................................................................................................... 11Separately Covered Pregnancy-Related Services ...................................................................... 11Extraordinary Circumstances With Pregnancy and/or Delivery .................................................. 12Complications of Pregnancy .................................................................................................... 12Unrelated Conditions .............................................................................................................. 12Health Professional Shortage Area Incentive Reimbursement ................................................... 12Services Provided Prior to Wisconsin Medicaid Eligibility ........................................................... 13Fee-for-Service Recipients Subsequently Enrolled in a Medicaid Managed Care Program ............ 13

Newborn Care ............................................................................................................................. 15

Newborn Reporting ................................................................................................................ 15Providers Required to Report Newborns ............................................................................. 15Newborn Report Submission .............................................................................................. 15Recipients Enrolled in Medicaid HMOs ................................................................................. 15Newborn Report Procedures .............................................................................................. 15

Newborn Screenings .............................................................................................................. 16Coverage and Reimbursement Procedures ........................................................................ 16

PHC 1411

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

Appendix .................................................................................................................................... 17

1. Wisconsin Medicaid-Allowable Procedure Codes for Certified Nurse Midwives ............................. 192. Wisconsin Medicaid-Allowable Local Procedure Codes for Nurse Midwives .................................. 213. Wisconsin Medicaid-Allowable Type of Service and Place of Service Codes ................................ 234. Wisconsin Medicaid-Allowable CPT and HCPCS Codes Covered in Place of Service “4” —

Recipient’s Home ................................................................................................................. 255. Sample CMS 1500 Claim Form — Nurse Midwife Services (Antepartum Care and Delivery

Including Postpartum Care With HPSA Modifier) ..................................................................... 276. Wisconsin Medicaid Newborn Report (for photocopying) .......................................................... 29

Glossary of Common Terms ........................................................................................................ 31

Index ......................................................................................................................................... 35

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

Nurse Midwife Services Handbook � September 2003 3

PThe Wisconsin Medicaid and BadgerCare NurseMidwife Services Handbook is issued to non-master’slevel nurse midwives (Medicaid certified as nurses inindependent practice). It contains information thatapplies to fee-for-service Medicaid providers. TheMedicaid information in the handbook applies to bothMedicaid and BadgerCare. Nurse midwives who areMedicaid certified as nurse practitioners should use theNurse Practitioner Services Handbook.

Wisconsin Medicaid and BadgerCare are administeredby the Department of Health and Family Services(DHFS). Within the DHFS, the Division of Health CareFinancing (DHCF) is directly responsible for managingWisconsin Medicaid and BadgerCare. As ofJanuary 2003, BadgerCare extends Medicaid coverageto uninsured children and parents with incomes at orbelow 185% of the federal poverty level and who meetother program requirements. BadgerCare recipientsreceive the same health benefits as Wisconsin Medicaidrecipients and their health care is administered throughthe same delivery system.

Medicaid and BadgerCare recipients enrolled in state-contracted HMOs are entitled to at least the samebenefits as fee-for-service recipients; however, HMOsmay establish their own requirements regarding priorauthorization, billing, etc. If you are an HMO networkprovider, contact your managed care organizationregarding its requirements. Information contained in thisand other Medicaid and BadgerCare publications is usedby the DHCF to resolve disputes regarding coveredbenefits that cannot be handled internally by HMOsunder managed care arrangements.

Verifying Recipient EligibilityWisconsin Medicaid providers should always verify arecipient’s eligibility before providing services, both todetermine eligibility for the current date and to discoverany limitations to the recipient’s coverage. WisconsinMedicaid’s Eligibility Verification System (EVS)provides eligibility information that providers can accessa number of ways.

Refer to the Important Telephone Numbers page at thebeginning of this section for detailed information on themethods of verifying eligibility.

Handbook OrganizationNurse midwives are issued the Nurse Midwife ServicesHandbook and the Physician Services Handbook.

Nurse midwives use this handbook in conjunction withthe Physician Services Handbook. The PhysicianServices Handbook consists of the following sections:

• Medicine and Surgery.• Laboratory and Radiology.• Anesthesia.

Each Medicaid-certified provider is issued a copy of theAll-Provider Handbook. The All-Provider Handbookincludes the following sections:

• Claims Submission.• Coordination of Benefits.• Covered and Noncovered Services.• Prior Authorization.• Provider Certification.• Provider Resources.• Provider Rights and Responsibilities.• Recipient Rights and Responsibilities.

Legal Framework ofWisconsin Medicaid andBadgerCareThe following laws and regulations provide the legalframework for Wisconsin Medicaid and BadgerCare:

Federal Law and Regulation• Law: United States Social Security Act; Title XIX

(42 US Code ss. 1396 and following) and Title XXI.• Regulation: Title 42 CFR Parts 430-498 — Public

Health.

Preface

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

4 Wisconsin Medicaid and BadgerCare � September 2003

Wisconsin Law and Regulation• Law: Wisconsin Statutes: Sections 49.43-49.499 and

49.665.• Regulation: Wisconsin Administrative Code,

Chapters HFS 101-108.

Handbooks and Wisconsin Medicaid and BadgerCareUpdates further interpret and implement these laws andregulations.

Handbooks and Updates organized by provider type,maximum allowable fee schedules, helpful telephonenumbers and addresses, Remittance and Statusmessages, and much more information about Wisconsin

Medicaid and BadgerCare are available at the followingWeb sites:

www.dhfs.state.wi.us/medicaid/www.dhfs.state.wi.us/badgercare/.

Medicaid Fiscal AgentThe DHFS contracts with a fiscal agent, which iscurrently EDS.

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

General Inform

ation

Nurse Midwife Services Handbook � September 2003 5

GGeneral InformationNurse midwives should use this handbook inconjunction with the Physician ServicesHandbook. The Nurse Midwife ServicesHandbook includes the following limitedinformation that applies to fee-for-serviceMedicaid-certified nurse midwives:

• Covered services, including obstetricservices.

• Protocols and collaborative agreements.• Provider eligibility and certification.• Provider numbers.• Reimbursement.

Nurse midwives should refer to the PhysicianServices Handbook for the followinginformation:

• Billing and reimbursement.• Evaluation and management services.• Health Personnel Shortage Areas.• Laboratory services.• Medicine services.• Radiology services.• Surgery services.

The Physician Services Handbook alsocontains the following forms for nurse midwifeuse:

• Breast Pump Order form.• Newborn Report form.• Provider Certification of Emergency for

Undocumented Aliens form (forphotocopying).

• Specialized Medical Vehicle TransportationPhysician Certification form (forphotocopying).

Provider Eligibility andCertification

Nurse Midwife CertificationNurse midwives who treat Medicaid recipientsare required to be Medicaid certified to receiveMedicaid reimbursement. This applies to nursemidwives whose services are reimbursedunder a physician’s or clinic’s Medicaidprovider number, as well as to those whoindependently submit claims to WisconsinMedicaid.

A Master’s degree-prepared nurse midwife iseligible to be Medicaid certified as a nursepractitioner. Medicaid-certified nursepractitioners have a broader range ofMedicaid-allowable services for which theymay be reimbursed and receive higherreimbursement. Nurse midwives Medicaid-certified as nurse practitioners should use theNurse Practitioner Services Handbook.

Nurse midwives who are not educated at theMaster’s degree prepared are Medicaidcertified as nurses in independent practice witha specialty of nurse midwife.

To be reimbursed by Wisconsin Medicaid, anurse midwife must be certified under HFS105.201, Wis. Admin. Code. A nurse midwifemust also be a professional nurse currentlylicensed by the Board of Nursing pursuant to s.441, Wis. Stats., and certified as a nursemidwife pursuant to s. 441.15, Wis. Stats.

Medicaid services performed by nursemidwives must be within the legal scope ofpractice as defined under the Wisconsin Boardof Nursing licensure or certification. Servicesperformed must be included in the individualnurse midwife’s protocols or a collaborative

NNurse midwivesshould use thishandbook inconjunction withthe PhysicianServicesHandbook.

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

Gen

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Info

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6 Wisconsin Medicaid and BadgerCare � September 2003

relationship with a physician as defined by theBoard of Nursing.

Pursuant to Board of Nursing Ch. N 8.10(7),Wis. Admin. Code, advanced practice nurseprescribers work in a collaborative relationshipwith a physician. (The collaborativerelationship means an advanced practice nurseprescriber works with a physician, “in eachother’s presence when necessary, to deliverhealth care services within the scope of thepractitioner’s professional expertise.”)

Advanced practice nurse prescribers whodispense drugs in addition to prescribing themshould obtain the appropriate Medicaidpharmacy publications. The Medicaid Web site(www.dhfs.state.wi.us/medicaid/) contains alist of all published materials for each Medicaidprovider type and many of the publicationsmay be downloaded. Providers may also callProvider Services at (800) 947-9627 or(608) 221-9883 if Internet access is notavailable.

Medicaid-certified nurse midwives who are notadvanced practice nurse prescribers practicein collaboration with a physician withpostgraduate training in obstetrics and pursuantto a written agreement with that physician,pursuant to the Board of Nursing s. 441.15,Wis. Stats. Collaboration is defined here tomean “a process that involves two or morehealth care professionals working together and,when necessary, in each other’s presence, andin which each health care professionalcontributes his or her expertise to provide morecomprehensive care than one health careprofessional alone can offer.”

Protocols/CollaborativeAgreementsPursuant to Board of Nursing Ch. N 8.10(7),Wis. Admin. Code, advanced practice nurseprescribers work in a collaborative relationshipwith a physician. (The collaborativerelationship means an advanced practice nurseprescriber works with a physician, “in eachother’s presence when necessary, to deliver

health care services within the scope of thepractitioner’s professional expertise.”) Theadvanced nurse prescriber and the physicianmust document this relationship.

Medicaid-certified nurse midwives who are notadvanced practice nurse prescribers practicein collaboration with a physician withpostgraduate training in obstetrics and pursuantto a written agreement with that physician,pursuant to Wisconsin statute for the Board ofNursing, chapter 441.15. Collaboration isdefined here to mean “a process that involvestwo or more health care professionals workingtogether and, when necessary, in each other’spresence, and in which each health careprofessional contributes his or her expertise toprovide more comprehensive care than onehealth care professional alone can offer.”

For purposes of Medicaid reimbursement, noservice which is a medical act and is listed inthis handbook or Physician Services Handbookmay be performed without a collaborativeagreement as required for advanced practicenurse prescribers (pursuant to N 8.10 Wis.Admin. Code) or nurse midwives (pursuant tos. 441.15), or protocols, written or verbalorders for registered nurses (pursuant to N6.03, Wis. Admin. Code).

Provider NumbersWisconsin Medicaid issues all providers,whether individuals, agencies, or institutions, aneight-digit provider number to bill WisconsinMedicaid for services provided to eligibleMedicaid recipients. A provider numberbelongs solely to the person, agency, orinstitution to whom it is issued. It is illegal for aMedicaid-certified provider to bill using aprovider number belonging to anotherMedicaid-certified provider.

A provider keeps the same provider number inthe event that he or she relocates, changesspecialties, or voluntarily withdraws fromWisconsin Medicaid and later chooses to bereinstated. (Notify Provider Maintenance ofchanges in location or of specialty by using the

MMedicaid-certifiednurse midwiveswho are notadvanced practicenurse prescriberspractice incollaboration witha physician withpostgraduatetraining inobstetrics andpursuant to theBoard of Nursings. 441.15, Wis.Stats.

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

General Inform

ation

Nurse Midwife Services Handbook � September 2003 7

Wisconsin Medicaid Provider Change ofAddress or Status Form, which may be foundin the September 2002 Wisconsin Medicaidand BadgerCare Update (2002-52), titled“Two All-Provider Handbook forms revised.”The Update and form are available on theMedicaid Web site at www.dhfs.state.wi.us/medicaid/.) A provider’s number is notreissued to another provider in the event oftermination from Wisconsin Medicaid.

Wisconsin Medicaid reimburses nurse midwifeservices under two types of provider numbers.Each type of provider number has itsdesignated uses and restrictions. The twotypes are:

• Billing/performing provider number.• Group billing number.

Billing/Performing ProviderNumber (Issued to NurseMidwives)Wisconsin Medicaid issues a billing/performingprovider number to nurse midwives that allowsthem to identify themselves on the CMS 1500claim form as either the biller of services or theperformer of services when a clinic or group isbilling for the services.

Nurse Midwives Who Submit Claims toWisconsin Medicaid as PerformingProviders Through a Physician or ClinicNurse midwives who submit claims toWisconsin Medicaid as performing providersare required to indicate their own providernumber in Element 24K of the CMS 1500claim form. The billing provider number of thephysician or clinic must be indicated inElement 33.

Nurse Midwives Who IndependentlySubmit Claims to Wisconsin MedicaidNurse midwives who directly submit claims toWisconsin Medicaid for services must indicatetheir provider number in Element 33 of theCMS 1500 claim form as the billing provider. Itis not necessary to indicate a provider numberin Element 24K.

Group Billing Number (Issued toClinics)Two or more nurse midwives can be issued agroup billing number which is primarily anaccounting convenience. A clinic or groupusing a group billing number receives onereimbursement and one Remittance and Status(R/S) Report for covered services performedby individual providers within the clinic orgroup.

Individual providers within a clinic or groupmust also be Medicaid certified because clinicsand groups are required to identify theperformer of the service on the claim form.(The performing provider’s Medicaid providernumber must be indicated in Element 24K ofthe CMS 1500 claim form when a group billingnumber is indicated in Element 33.) Ordinarily,a claim billed with only a group billing numberis denied reimbursement. Refer to the CMS1500 claim form completion instructions in thePhysician Services Handbook for moreinformation.

Medicaid-Covered NurseMidwife ServicesNurse midwives are limited to providing thefollowing categories of Medicaid-coveredservices:

• Family planning services.• Laboratory services.• Obstetric services.• Office and outpatient visits.• Tuberculosis (TB)-related services.

The practice of nurse midwifery means themanagement of women’s health care,pregnancy, childbirth, postpartum care fornewborns, family planning, and gynecologicalservices consistent with the standards ofpractice of the American College of NurseMidwives and the education, training, andexperience of the nurse midwife (Board ofNursing s. 441.15, Wis. Stats.).

NNurse midwivesare limited toproviding thefollowingcategories ofMedicaid-coveredservices:• Family planning

services.• Laboratory

services.• Obstetric

services.• Office and

outpatient visits.• Tuberculosis

(TB)-relatedservices.

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

Gen

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8 Wisconsin Medicaid and BadgerCare � September 2003

Nurse midwives should refer to Appendix 1 ofthis handbook for a list of allowable procedurecodes for nurse midwives and Appendix 2 fora list of allowable local procedure codes.Appendix 3 lists the allowable Medicaid-covered type of service (TOS) and place ofservice (POS) codes for nurse midwives.

Wisconsin Medicaid reimburses only for thoseservices that are medically necessary,appropriate, and, to the extent that alternativeservices are available, the most cost effective.

All nurse midwife services must be fullydocumented in the recipient’s medical recordand available for inspection or review byMedicaid auditors.

Refer to HFS 107.03, Wis. Admin. Code, forservices not covered by Wisconsin Medicaid.Refer to the Covered and NoncoveredServices section of the All-Provider Handbookfor a partial list of the noncovered services.

Reimbursement forNurse Midwives

Maximum Allowable FeesThe maximum allowable fee is the maximumamount that Wisconsin Medicaid will reimbursea provider for an allowable procedure code.Maximum allowable fees are based on variousfactors, including a review of usual andcustomary charges submitted to WisconsinMedicaid, the Wisconsin State Legislature’sbudgetary constraints, and other relevanteconomic limitations.

Wisconsin Medicaid reimburses nursemidwives 100% of the physician maximumallowable fee for laboratory services andinjections and 90% of the physician maximumallowable fee for other physician services.Nurse midwives are required to use theappropriate TOS and POS codes as listed inAppendix 3 of this handbook.

Nurse midwives may obtain a copy of theNurse Midwife Services Maximum AllowableFee Schedule from one of the followingsources:

• An electronic version on WisconsinMedicaid’s Web site atwww.dhfs.state.wi.us/medicaid/.

• Purchase a paper copy by writing to:

Wisconsin MedicaidProvider Maintenance6406 Bridge RdMadison WI 53784-0006

Call Provider Services at (800) 947-9627or (608) 221-9883 for the cost of the feeschedule.

Enhanced ReimbursementWisconsin Medicaid provides an enhancedreimbursement rate for the following services:

• Health Professional Shortage Areas(HPSAs). Wisconsin Medicaid providesenhanced reimbursement to providerswhen one or both of the following apply:� The performing or billing provider is

located in a HPSA-eligible ZIP code.� The recipient has a residential address

(according to Medicaid’s eligibilityrecords) within a HPSA-eligible ZIPcode.(Note: Nurse midwives receive a20% incentive payment for HPSA-related primary care services and a50% incentive bonus for HPSA-eligible obstetric services, when theabove criteria are met.)

• Pediatric services. Wisconsin Medicaidprovides enhanced reimbursement foroffice and other outpatient services andemergency department services forrecipients 18 years of age and under.

Refer to the Medicine and Surgery section ofthe Physician Services Handbook for moreinformation about these enhancedreimbursement.

NNurse midwivesshould refer toAppendix 1 of thishandbook for a listof allowableprocedure codesfor nursemidwives andAppendix 2 for alist of allowablelocal procedurecodes.

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

Obstetric Services

Nurse Midwife Services Handbook � September 2003 9

OObstetric ServicesWisconsin Medicaid offers providers choicesof how and when to file claims for obstetric(OB) care. Providers may choose to submitclaims using either the separate OBcomponent procedure codes as they areperformed or the appropriate global OBprocedure code with the date of delivery as thedate of service (DOS).

Wisconsin Medicaid will not reimburseindividual antepartum care, delivery, orpostpartum care codes if a provider alsosubmits a claim for global OB care codes forthe same recipient during the same pregnancyor delivery. The exception to this rule is in thecase of multiple births, where more than onedelivery may be reimbursed (see “Delivery”section for details).

Separate Obstetric CareComponentsProviders should use the following guidelineswhen submitting claims for separate OBcomponents.

Antepartum CareAntepartum care includes dipstickurinalysis, routine exams andrecording of weight, blood pressure,and fetal heart tones.

Providers should refer to the table onthis page as a guide for submittingclaims for a specific number ofantepartum care visits. Providersshould provide all antepartum carevisits before submitting a claim toWisconsin Medicaid.

Providers should use local procedurecodes W6000 — “antepartum care;initial visit” — and W6001 —“antepartum care; two or three visits”— when submitting claims for the first

through third antepartum care visits with aprovider or provider group. For example, if atotal of two to three antepartum care visits isperformed, the provider should indicateprocedure code W6000 and a quantity of “1.0”for the first DOS. For the second and thirdvisits, the provider should indicate procedurecode W6001 and a quantity of “1.0” or “2.0,”as indicated in the table. The date of the lastantepartum care visit is the DOS.

Note: Do not use evaluation and managementprocedure codes when submitting claims forthe first three antepartum care visits. Use ofthese codes may result in improperreimbursement.

Similarly, for Current ProceduralTerminology (CPT) codes 59425 —“antepartum care only; 4-6 visits” — and59426 — “antepartum care only; 7 or morevisits” — the provider should indicate the dateof the last antepartum care visit as the DOS.The quantity indicated for these two codesmay not exceed “1.0.”

Antepartum Care Claims Submission Guide

TotalVisit(s)

ProcedureCode* Description Quantity

1 W6000 Antepartum care;initial visit 1.0

W6000 Antepartum care;initial visit

1.02

W6001Antepartum care;two or three visits 1.0

W6000 Antepartum care;initial visit

1.03

W6001Antepartum care;two or three visits 2.0

4-6 59425 Antepartum careonly; 4-6 visits 1.0

7+ 59426 7 or morevisits 1.0

*Nurse midwives should submit claims with types ofservice (TOS) "9" for these codes.

WWisconsinMedicaid will notreimburseindividualantepartum care,delivery, orpostpartum carecodes if a provideralso submits aclaim for global OBcare codes for thesame recipientduring the samepregnancy ordelivery.

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

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10 Wisconsin Medicaid and BadgerCare � September 2003

Occasionally, a provider may be unsure ofwhether a recipient has had previousantepartum care visits with another provider. Ifthe recipient is unable to provide thisinformation, the provider should assume thefirst time he or she sees the recipient is the firstantepartum visit.

Note: Reimbursement for procedure codesW6000, W6001, 59425, and 59426 is limited toonce per pregnancy, per recipient, per billingprovider. A telephone call between patients andproviders does not qualify as an antepartumvisit.

DeliveryDelivery includes patient preparation,placement of fetal heart or uterine monitors,insertion of catheters, delivery of the child andplacenta, injections of local anesthesia,induction of labor, and artificial rupture ofmembranes.

Providers who perform deliveries may submitclaims using the appropriate delivery codes. Aclinic or group may submit claims for thedelivery component separately and shouldindicate the provider who performed thedelivery as the performing provider, rather thanthe primary OB provider.

When there are multiple deliveries (e.g., twins,triplets), providers should submit one claim forall of the deliveries. On the first detail line ofthe CMS 1500 claim form, indicate theappropriate procedure code for the firstdelivery. Indicate additional births on separatedetail lines of the claim form, using theappropriate delivery procedure code for eachdelivery.

Wisconsin Medicaid does not recognizemodifiers “-51” or “-22.”

Induction of LaborWisconsin Medicaid covers induction of laboronly when the service is documented in therecipient’s medical record and whenperformed on a date other than the delivery

date. Providers should submit claims for thisservice with CPT procedure code 59899 —“Unlisted procedure, maternity care anddelivery” — with supporting documentationattached to the claim.

Postpartum CarePostpartum care includes all routinemanagement and care of the postpartumpatient including exploration of the uterus,episiotomy and repair, repair of obstetricallacerations and placement of hemostatic packsor agents. These are part of both the post-delivery and post-hospital office visits, both ofwhich must occur in order to receivereimbursement for postpartum care or globalobstetric care.

Wisconsin Medicaid reimbursement forpostpartum care includes hospital and officevisits following delivery. In accordance withthe standards of the American College ofObstetricians and Gynecologists, postpartumcare includes both the routine post-deliveryhospital care and an outpatient/office visit.Post-delivery hospital care alone is included inthe reimbursement for delivery. Whensubmitting claims for postpartum care, theDOS is the date of the post-hospital dischargeoffice visit. In order to receive reimbursement,the recipient must be seen in the office. Thelength of time between a delivery and theoffice postpartum visit should be dictated bygood medical practice. Wisconsin Medicaiddoes not dictate an “appropriate” period forpostpartum care; however, the industrystandard is six to eight weeks followingdelivery. A telephone call between patients andproviders does not qualify as a postpartumvisit.

Delivery and Postpartum CareProviders who perform both the delivery andpostpartum care may use either the separatedelivery and postpartum codes or the deliveryincluding postpartum care CPT procedurecodes 59410, 59515, 59614, or 59622, asappropriate. The DOS for the combinationcodes is the delivery date. However, if the

WWisconsinMedicaid coversinduction of laboronly when theservice isdocumented in therecipient’s medicalrecord and whenperformed on adate other thanthe delivery date.

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

Obstetric Services

Nurse Midwife Services Handbook � September 2003 11

recipient fails to return for the postpartum visit,the provider must adjust the claim to reflectdelivery only or the reimbursement will berecouped through audit.

Global Obstetric CareProviders may submit claims using global OBcodes. Providers choosing to submit claims forglobal OB care must perform all of thefollowing:

• A minimum of six antepartum visits.• Delivery.• The post-delivery hospital visit and a

minimum of one postpartum office orhome visit.

When submitting claims for global OB care,providers should use the single mostappropriate CPT OB procedure code and asingle charge for the service. Use the date ofdelivery as the DOS.

All services must be performed to receivereimbursement for global obstetric care.Providers are required to provide all six (ormore) antepartum visits, delivery, and thepostpartum office visit in order to receivereimbursement for global OB care. If fewerthan six antepartum visits have beenperformed, the provider performing thedelivery may submit a claim using theappropriate delivery procedure code and, asappropriate, antepartum and postpartum visitprocedure codes.

If the required postpartum office visit does notoccur following claims submission for theglobal delivery, the provider must adjust theclaim to reflect antepartum care and delivery ifthere is no documentation of a postpartum visitin the patient’s medical record. (Refer to thesection on postpartum care.)

Group Claims Submission forGlobal Obstetric CareWhen several OB providers in the same clinicor medical/surgical group practice perform thedelivery and provide antepartum and

postpartum care to the same recipient duringthe period of pregnancy, the clinic may chooseto submit a claim using a single procedure codefor the service. When submitting the claims,providers should indicate the group Medicaidbilling number and identify the primary OBprovider as the performing provider.

Emergency DeliveriesEmergency deliveries that are performedoutside either an inpatient hospital setting or thepatient’s home are covered if documentation(i.e., history, physical examination, orsummaries) attached to the paper claimsupports the procedure’s urgent or emergentnature. Nurse midwives should call ProviderServices at (800) 947-9627 or (608) 221-9883for deliveries performed outside of an inpatienthospital setting or a recipient’s home. Claimsfor these situations are special handled.

Home DeliveriesWisconsin Medicaid allows certified nursemidwives to perform maternity care anddelivery in a recipient’s home (place of service[POS] “4”).

Refer to Appendix 4 of this handbook for a listof allowable maternity care and deliveryprocedure codes allowed in POS “4.”

Separately CoveredPregnancy-RelatedServicesServices that may be reimbursed separatelyfrom the global or component obstetricalservices include:

• Administration of RH immune globulin.• Amniocentesis, chorionic villous sampling,

and cordocentesis.• Epidural anesthesia. (Refer to the

Physician Services Handbook for epiduralanesthesia claims submission information.)

• External cephalic version.• Fetal biophysical profiles.

WWhen submittingclaims for globalOB care, providersshould use thesingle mostappropriate CPTOB procedurecode and a singlecharge for theservice. Use thedate of delivery asthe DOS.

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

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12 Wisconsin Medicaid and BadgerCare � September 2003

• Fetal blood scalp sampling.• Fetal contraction stress and non-stress

tests.• Harvesting and storage of cord blood.• Insertion of cervical dilator.• Laboratory tests, excluding dipstick

urinalysis.• Obstetrical ultrasound and fetal

echocardiography.• Sterilization. (Refer to the Physician

Services Handbook for sterilizationlimitations.)

• Surgical complications of pregnancy (e.g.,incompetent cervix, hernia repair, ovariancyst, Bartholin cyst, ruptured uterus, orappendicitis).

ExtraordinaryCircumstances WithPregnancy and/orDeliveryProviders treating recipients whosepregnancies require more than the typicalnumber of antepartum visits or result incomplications during delivery may seekadditional reimbursement by initially submittingand being reimbursed for a claim for OBservices. Providers are required to then submitan Adjustment Request Form that includes acopy of the medical record and/or deliveryreport specifying the medical reasons for theextraordinary number of antepartum orpostpartum visits. A medical consultant willreview the materials and determine theappropriate level of reimbursement.

Wisconsin Medicaid does not recognize the“-22” modifier.

Complications ofPregnancyIf a nurse midwife encounters a situationduring delivery which requires the assistanceof a physician, the physician performing the

delivery must bill for the delivery. The nursemidwife may be reimbursed for his or herservice by submitting a paper claim using theCPT procedure code 99499 (unlistedevaluation and management services) inaddition to any antepartum and postpartumcare provided. Documentation on the medicalnecessity of the services provided must besubmitted with the claim. Reimbursement isdetermined by the Medicaid medicalconsultant.

Unrelated ConditionsAny evaluation and management servicesperformed that are related to the pregnancyare included in reimbursement for obstetricalcare. However, conditions unrelated to thepregnancy may be separately reimbursed byWisconsin Medicaid. These include, but are notlimited to:

• Chronic hypertension.• Diabetes.• Management of cardiac, neurological, or

pulmonary problems.• Other conditions (e.g., urinary tract

infections) with a diagnosis other thancomplication of pregnancy.

Health ProfessionalShortage Area IncentiveReimbursementAll OB procedure codes are eligible for theHealth Professional Shortage Area (HPSA)incentive reimbursement. Submit claimsindicating the appropriate HPSA modifier“HP” or “HK” to receive a 50% bonusincentive. Refer to the Billing andReimbursement chapter of the Medicine andSurgery section of the Physician ServicesHandbook for further information.

AAll OB procedurecodes are eligiblefor the HealthProfessionalShortage Area(HPSA) incentivereimbursement.

ARCHIVAL USE ONLY Refer to the Online Handbook

for current policy

Obstetric Services

Nurse Midwife Services Handbook � September 2003 13

Services Provided Priorto Wisconsin MedicaidEligibilityWisconsin Medicaid OB payments apply onlyto services provided while the person is eligibleas a Medicaid recipient. Services providedprior to Wisconsin Medicaid eligibility are notincluded in the number of antepartum visits, thedelivery, or postpartum care.

Fee-for-ServiceRecipients SubsequentlyEnrolled in a MedicaidManaged Care ProgramWisconsin Medicaid will reimburse theequivalent of one global OB fee per recipient,per delivery, per single provider or providergroup, whether the reimbursement is madethrough fee-for-service or through a Medicaidmanaged care program.

When a recipient who is initially eligible forfee-for-service Medicaid enrolls in a Medicaidmanaged care program during her pregnancy,and receives care from the same provider or

clinic when eligible for Medicaid fee-for-service and when enrolled in a managed careprogram, her provider may be paid a global feeby the managed care program after fee-for-service has paid for antepartum care. Theprovider is then required to submit anadjustment(s) to have fee-for-service Medicaidpayment recouped.

If the provider does not submit theadjustment(s) in this situation, WisconsinMedicaid will recoup the fee-for-servicepayment(s) through audit. If the recipientreceives less than global OB care whileenrolled in the Medicaid managed careprogram, Wisconsin Medicaid reimburses herprovider no more than the global maximumallowable fee or the sum of the individualcomponents for services. Wisconsin Medicaidwill, on audit, recoup any amount paid underfee-for-service that is above the global fee orthe combined maximum allowable fee for theservices if billed separately.

WWisconsinMedicaid willreimburse theequivalent of oneglobal OB fee perrecipient, perdelivery, per singleprovider orprovider group,whether thereimbursement ismade through fee-for-service orthrough aMedicaid managedcare program.

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New

born Care

Nurse Midwife Services Handbook � September 2003 15

NNewborn Care

Newborn ReportingProviders are required to promptly reportnewborns born to fee-for-service Medicaidrecipients to Wisconsin Medicaid. Establishinga newborn’s Medicaid eligibility results inbetter health outcomes and fewer delays inprovider reimbursement. Refer to Appendix 6of this section for a Wisconsin MedicaidNewborn Report form for photocopying.Providers may also obtain the Newborn Reportfrom the forms section of the Medicaid Website at www.dhfs.state.wi.us/medicaid.

Providers Required to ReportNewbornsHospitals, Medicaid HMOs, physicians, nursepractitioners, and nurse midwives may reportnewborns born to Medicaid recipients bysubmitting a Wisconsin Medicaid NewbornReport, or another form developed by theprovider that contains all the same information,to Wisconsin Medicaid.

Physicians, nurse practitioners, and nursemidwives should only complete a NewbornReport if the recipient is not enrolled in anHMO and the birth occurs outside a hospitalsetting. Otherwise, the Medicaid HMO orhospital should complete the form.

Newborn Report SubmissionProviders have the option of sending newbornreports in a summary format on a weekly basisto Wisconsin Medicaid or individual reports foreach newborn. However, the summary reportmust contain all the information provided in theNewborn Report.

If possible, the Newborn Report form shouldbe submitted to Wisconsin Medicaid with thechild’s given name (first and last name), ratherthan “baby boy” or “baby girl” as the firstname. The four-digit year should be includedwhen reporting the child’s date of birth. (To

report a child’s date of death, the two- or four-digit year format may be used.) WisconsinMedicaid still requires providers to submit aNewborn Report in instances in which thebaby is born alive, but does not survive.

Submit the Newborn Report form to WisconsinMedicaid by mail or fax:

Wisconsin MedicaidPO Box 6470Madison WI 53716Fax: (608) 224-6318

This information on newborn reporting pertainsto the birth of a newborn to a Medicaidrecipient who is not enrolled in an HMO.

Recipients Enrolled in MedicaidHMOsUnder the Medicaid managed care contract,HMOs are required to report to WisconsinMedicaid the birth of a newborn to a motherenrolled in an HMO. Because of thisrequirement, hospitals and HMOs shouldcoordinate the newborn reporting function toprevent duplicate reporting by the hospital andHMO of the same newborn. Following theseprocedures assures more timelyreimbursement for services provided to infants.

Newborn Report ProceduresOnce the completed Newborn Report issubmitted to Wisconsin Medicaid, the followingprocedures take place:• A pseudo (temporary) Medicaid

identification number is assigned to thenewborn, regardless of whether thenewborn is named (if Medicaid eligibility isnot yet on file).

• A Medicaid Forward card is created forthe child and sent to the mother as soon asthe child’s eligibility is put on file.

PProviders arerequired topromptly reportnewborns born tofee-for-serviceMedicaidrecipients toWisconsinMedicaid.

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16 Wisconsin Medicaid and BadgerCare � September 2003

• Wisconsin Medicaid sends a letter to themother, notifying her of the child’seligibility. The letter also contains astatement that the mother is required tosign, stating that the baby has continued tolive with her since birth. She must sendthis statement to her county or tribaleligibility worker in the envelope providedand is required to tell her eligibility workerthat she has a new baby with a temporaryMedicaid identification number.

• A copy of this letter is also sent to thecounty economic support agency.

• Once the mother notifies her worker andher child has received a Social Securitynumber, a permanent Medicaid number isassigned to the child.

• The provider receives a copy of theeligibility notification letter sent to thechild’s mother as confirmation.

Providers with questions regarding newborneligibility may contact Provider Services at(800) 947-9627 or (608) 221-9883.

Newborn ScreeningsProviders are required to test newborns forcertain congenital and metabolic disorders, pers. 253.13, Wis. Stats. These tests require aprepaid filter paper card purchased from theState Laboratory of Hygiene. WisconsinMedicaid reimburses providers for purchasingthe prepaid filter paper cards and thelaboratory handling fee for newborn screeningsperformed outside a hospital setting.

Coverage and ReimbursementProceduresThe following is a list of the CPT codes withallowable POS and/or TOS codes andinstructions for submitting claims to WisconsinMedicaid for Medicaid-covered newbornscreening services.

• 86849 — Unlisted immunology procedure.� Wisconsin Medicaid reimburses this

procedure code for prepaid filterpaper cards purchased from the StateLaboratory of Hygiene.

� This procedure code is allowable inPOS “3” (doctor’s office) or POS “4”(home) for TOS “5” (diagnosticlaboratory — total charge).

� In Element 19 of the CMS 1500 claimform enter “Newborn screeningstate lab card” or attachdocumentation to a paper claim toindicate the claim is for a prepaid filterpaper card for newborn screeningpurchased from the Wisconsin StateLaboratory of Hygiene.

• 99000 — Handling and/or conveyance ofspecimen for transfer from the physician’soffice to a laboratory.� Wisconsin Medicaid reimburses this

procedure code for the transfer of thespecimen from the physician’s officeto the State Laboratory of Hygiene.

� Certified nurse midwives who are notMedicaid certified as nursepractitioners use TOS “9” (other) forthis procedure code.

� Nurse midwives must check the“outside lab” box “Yes” (Element 20on CMS 1500 claim form).

� Indicate a quantity of 1.0 since thespecimen is going to only one lab.

• 99001 — Handling and/or conveyance ofspecimen for transfer from the patient inother than a physician’s office to alaboratory.� Wisconsin Medicaid covers this

procedure code for the transfer of thespecimen from a location other than aphysician’s office to the StateLaboratory of Hygiene.

� Certified nurse midwives who are notcertified as nurse practitioners useTOS “9” (other) for this procedurecode.

� Nurse midwives must check the“outside lab” box “Yes” (Element 20on CMS 1500 claim form).

� Indicate a quantity of 1.0 since thespecimen is going to only one lab.

PProviders withquestionsregardingnewborn eligibilitymay contactProvider Servicesat (800) 947-9627or(608) 221-9883.

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Appendix

Nurse Midwife Services Handbook � September 2003 17

AAppendix

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18 Wisconsin Medicaid and BadgerCare � September 2003

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Appendix

Nurse Midwife Services Handbook � September 2003 19

Appendix 1

Wisconsin Medicaid-Allowable Procedure Codes forCertified Nurse Midwives

The following chart is periodically revised. Refer to Appendix 3 of this handbook for applicable type of service (TOS) codesand descriptions.

Current Procedural Terminology (CPT) Procedure Codes

Service Code(s) Type ofService

Insertion, implantable contraceptive capsules 11975 2Removal, implantable contraceptive capsules 11976 2Removal with reinsertion, implantable contraceptive capsules 11977 2Intrauterine Device — Female Genital System 58300-58301 2

59025, 59300, 59400-59430,59610-59614, W6000-W6001

9Maternity Care and Delivery

59400-59410, 59514,59610-59614

8

76816 4Diagnostic Ultrasound76819 4, Q, U

Urinalysis 81001-81003 5Chemistry 82565, 82950, 84132, 84295,

84450, 84520, 84550, 847035

Hematology and Coagulation 85018, 85025, 85027 5Immunology 86592, 86703, 86762 5Unlisted Immunology Procedure 86849 (Newborn screening

card)5

Transfusion Medicine 86850, 86900 5Microbiology 87070, 87081, 87210, 87340,

87491, 878805

Cytopathology 88164 5Immune Globulins 90384 1Therapeutic or Diagnostic Infusions 90780-90781 1Therapeutic, Prophylactic or Diagnostic Injections 90782 9

99000-99001 9Special Services, Procedures and Reports99070 1

Evaluation and Management 99201-99215 9Prolonged Services* 99354*-99355* 9

99432 999436 1

Newborn Care

99440 9Unlisted Evaluation and Management Service 99499 9Preventive Medicine 99381, 99391 9*This procedure code must be submitted on a HCFA 1500 claim form with documentation attached to the claim showingmedical necessity. This code should be billed by a certified nurse midwife (CNM) only in place of service "4" (home) when theCNM attends the labor of a patient and subsequently admits the patient to the hospital for the birth.

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20 Wisconsin Medicaid and BadgerCare � September 2003

Healthcare Common Procedure Coding System (HCPCS) Procedure Codes

Service CodeType ofService

Injection, ampicillin sodium/sulbactam sodium, per 1.5 gram J0295 1Injection, medroxyprogesterone acetate for contraceptive use, 150mg

J1055 9

Injection, methylergonovine maleate, [Methergine Maleate], up to0.2 mg

J2210 1

Injection, oxytetracycline HCl, up to 50 mg J2460 1Injection, RHo(D) immune globulin, human, [Rhogam], one dosepackage

J2790 1

Injection, phytonadione (vitamin K), per 1 mg J3430 1Intrauterine copper contraceptive J7300 1Levonorgestrel-releasing intrauterine contraceptive system, 52 mg J7302 1

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Appendix

Nurse Midwife Services Handbook � September 2003 21

Appendix 2

Wisconsin Medicaid-Allowable Local Procedure Codesfor Nurse Midwives

Procedure Code DescriptionType ofService

Maternity Care

W6000 Antepartum care; initial visit 9

W6001 two or three visits 9

Family Planning Services

W6200 Intrauterine device — progesterone 1

W6201 Diaphragm 9

W6202 Jellies, creams, foams 9

W6203 Suppositories 9

W6204 Sponges (per 1) 9

W6205 Condoms (per 1) 9

W6206 Natural family planning supplies 9

W6207 Oral contraceptives 9

W6208 Female condom 9

W6209 Cervical cap 9

W6210 Family planning pharmaceutical visit; includes oralcontraceptives 9

W6211 initial visit, non-comprehensive 9

W6212 annual visit, non-comprehensive 9

Tuberculosis (TB)-Related Procedures

W6271 Directly observed preventive therapy — TB-infected only 1

W6272 Monitoring of TB symptoms — TB-infected only 1

W6273 Patient education and anticipatory guidance —TB-infected only

1

W6274 Direct observation of therapy — suspect or confirmedactive TB case 1

W6275 Monitoring of TB symptoms — suspect or confirmedactive TB case 1

W6276Patient education and anticipatory guidance — suspect orconfirmed active TB case 1

The following chart is periodically revised. Refer to Appendix 3 of this handbook for applicable type of service codes anddescriptions.

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22 Wisconsin Medicaid and BadgerCare � September 2003

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Appendix

Nurse Midwife Services Handbook � September 2003 23

Appendix 3

Wisconsin Medicaid-Allowable Type of Service andPlace of Service Codes

Type ofService Description

1 Medical care, injections, HealthCheck (EPSDT)

2 Surgery

4 Diagnostic X-ray (total charge)/Ultrasound (total charge)

5 Diagnostic lab (total charge)HealthCheck lab

8 Assistant surgery

9 Other

Place ofService Description

0 Other

1 Inpatient hospital

2 Outpatient hospital

3 Office

4 Home

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24 Wisconsin Medicaid and BadgerCare � September 2003

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Appendix

Nurse Midwife Services Handbook � September 2003 25

Appendix 4

Wisconsin Medicaid-Allowable Procedure Codes Covered inPlace of Service “4” — Recipient’s Home

ProcedureCode Description Type of

Service

59300 Episiotomy or vaginal repair, by other than attending physician 9

59400 Routine obstetric care including antepartum care, vaginal delivery (with orwithout episiotomy and/or forceps) and postpartum care 8, 9

59409 Vaginal delivery only (with or without episiotomy and/or forceps); 8, 9

59410 including postpartum care 8, 9

59414 Delivery of placenta (separate procedure) 9

59425 Antepartum care only; 4-6 visits 9

59426 7 or more visits 9

59430 Postpartum care only (separate procedure) 9

59610 Routine obstetric care including antepartum care, vaginal delivery (with orwithout episiotomy and/or forceps) and postpartum care, after previouscesarean delivery

8, 9

59612 Vaginal delivery only, after previous cesarean delivery (with or withoutepisiotomy and/or forceps);

8. 9

59614 including postpartum care 8, 9

90384 Rho(D) immune globulin (Rhlg), human, full-dose, for intramuscular use 1

90780 Intravenous infusion for therapy/diagnosis, administered by physician orunder direct supervision of physician; up to one hour 1

90781 each additional hour, up to eight (8) hours (List separately in additionto code for primary procedure) 1

90782 Therapeutic, prophylactic or diagnostic injection (specify materialinjected); subcutaneous or intramuscular

1

99070 Supplies and materials (except spectacles), provided by the physicianover and above those usually included with the office visit or otherservices rendered (list drugs, trays, supplies, or materials provided)

1, 2

99354* Prolonged physician service in the office or other outpatient settingrequiring direct (face-to-face) patient contact beyond the usual service(eg, prolonged care and treatment of an acute asthmatic patient in anoutpatient setting); first hour (List separately in addition to code for officeor other outpatient Evaluation and Management service)

9

99355* each additional 30 minutes (list separately in addition to code forprolonged physician service)

9

99440 Newborn resuscitation; provision of positive pressure ventilation and/orchest compressions in the presence of acute inadequate ventilationand/or cardiac output

9

*This procedure code must be submitted on a HCFA 1500 claim form with documentation attached to the claim showingmedical necessity. This code should be billed by a certified nurse midwife (CNM) only in place of service "4" (home) when theCNM attends the labor of a patient and subsequently admits the patient to the hospital for the birth.

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26 Wisconsin Medicaid and BadgerCare � September 2003

ProcedureCode Description Type of

Service

J0295 Injection, ampicillin sodium/sulbactam sodium, per 1.5 gram 1

J2210 Injection, methylergonovine maleate, [Methergine Maleate], up to 0.2 mg 1

J2460 Injection, oxytetracycline HC1, up to 50 mg 1

J3430 Injection, phytonadione (vitamin K), per 1 mg 1

W6000 Antepartum care; initial visit 9

W6001 two or three visits 9

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Appendix

Nurse Midwife Services Handbook � September 2003 27

P 1234567890

Recipient, Im A. MM DD YY X

609 Willow St

Anytown WI

55555 XXX XXX-XXXX

OI-P

659.80

MM DD YY 3 9 59426 HP 1 XXX XX 1.0

MM DD YY 1 9 59410 HP 1 XXX XX 1.0

1234JED XXX XX XXX XX XXX XX

MM/DD/YY

I.M. Nurse Midwife1 W. WilliamsAnytown, WI 55555 87654321

Appendix 5

Sample CMS 1500 Claim Form — Nurse Midwife Services(Antepartum Care and Delivery Including Postpartum Care With

Health Professional Shortage Area Modifier)

X

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28 Wisconsin Medicaid and BadgerCare � September 2003

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Appendix

Nurse Midwife Services Handbook � September 2003 29

Appendix 6

Wisconsin Medicaid Newborn Report(for photocopying)

(A copy of the Wisconsin Medicaid Newborn Report is located on the following page.)

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for current policy

DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSINDivision of Health Care FinancingHCF 1165 (Rev. 01/03)

WISCONSIN MEDICAIDNEWBORN REPORT

Wisconsin Medicaid requires information to enable Medicaid to authorize and pay for medical services provided to eligiblerecipients.

Recipients are required to give providers full, correct, and truthful information for the submission of correct and complete claims forMedicaid reimbursement. This information should include, but is not limited to, information concerning eligibility status, accuratename, address, and Medicaid identification number (HFS 104.02[4], Wis. Admin. Code).

Under s. 49.45(4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and isused for purposes directly related to Medicaid administration such as determining eligibility of the applicant, processing priorauthorization (PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by theform may result in denial of Medicaid payment for the services.

The use of this form is voluntary and providers may develop their own form as long as it includes all the information on this form.

INSTRUCTIONS1. Type or print clearly.2. All requested information must be provided.3. In multiple birth situations, a separate Newborn Report must be filled out for each birth.4. For more information on newborn reporting, contact Wisconsin Medicaid Provider Services at (800) 947-9627 or

(608) 221-9883. Mail or fax completed forms to:

Wisconsin MedicaidManaged CarePO Box 6470Madison WI 53716Fax (608) 224-6318

SECTION I — HOSPITAL (OR OTHER PROVIDER) INFORMATIONName — Hospital (or Other Provider) Wisconsin Medicaid Provider Number

(eight digits)

Name — Contact Person Telephone Number — Contact Person

( )

SECTION II — NEWBORN INFORMATIONName — Newborn (First, Middle Initial, Last) Date of Birth (MM/DD/YYYY)

Sex

� Female � Male

Date of Death, if applicable (MM/DD/YYYY)

Multiple Births

� Yes � No If yes, complete a form for each birth.

SECTION III — MOTHER INFORMATIONName — Mother

Medicaid Identification Number — Mother

Medicaid Identification Number — Case Head

Address (Street Address, City, State, and Zip Code)

SECTION IV — AUTHORIZATIONThis information is accurate to the best of my knowledge.SIGNATURE — Hospital (or Other Provider) Representative Date Signed

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Nurse Midwife Services Handbook � September 2003 31

Glossary

Advanced Practice Nurse PrescriberAn advanced practice nurse prescriber (APNP) is aregistered nurse with advanced training and with additionalcertification by the Board of Nursing and who is able toorder diagnostic procedures and issue prescription orders.Advanced practice nurse prescribers work in acollaborative relationship with a physician as defined bythe Board of Nursing Chapter N 8.10, Wis. Admin. Code.

BadgerCareBadgerCare extends Medicaid coverage through aMedicaid expansion under Titles XIX and XXI touninsured children and parents with incomes at or below185% of the federal poverty level and who meet otherprogram requirements. The goal of BadgerCare is to fillthe gap between Medicaid and private insurance withoutsupplanting or “crowding out” private insurance.

BadgerCare benefits are identical to the benefits andservices covered by Wisconsin Medicaid and recipients’health care is administered through the same deliverysystem.

CMSCenters for Medicare and Medicaid Services. An agencyhoused within the U.S. Department of Health and HumanServices, CMS administers Medicare, Medicaid, relatedquality assurance programs and other programs. Formerlyknown as the Health Care Financing Administration(HCFA).

CollaborationCollaboration for advanced practice nurse prescribersmeans a process that involves two or more health careprofessionals working together and, when necessary, ineach other’s presence, and in which each health careprofessional contributes his or her expertise to providemore comprehensive care than one health careprofessional alone can offer. (Board of Nursing ChapterN 8.10, Wis. Admin. Code.)

CPTCurrent Procedural Terminology. A listing of descriptiveterms and codes for reporting medical, surgical,therapeutic, and diagnostic procedures. These codes aredeveloped, updated, and published annually by theAmerican Medical Association and adopted for billingpurposes by the Centers for Medicare and MedicaidServices (CMS) and Wisconsin Medicaid.

CRNACertified registered nurse anesthetists. A nurse withadvanced training in the selection and administration ofanesthesia agents and the provision of anesthesia care,who operates independently or under the medical directionof an anesthesiologist, based on standard medical practice.

DHCFDivision of Health Care Financing. The DHCFadministers Wisconsin Medicaid for the Department ofHealth and Family Services (DHFS) under statutoryprovisions, administrative rules, and the state’s Medicaidplan. The state’s Medicaid plan is a comprehensivedescription of the state’s Medicaid program that providesthe Centers for Medicare and Medicaid Services (CMS)and the U.S. Department of Health and Human Services(DHHS), assurances that the program is administered inconformity with federal law and CMS policy.

DHFSWisconsin Department of Health and Family Services.The DHFS administers the Wisconsin Medicaid program.Its primary mission is to foster healthy, self-reliantindividuals and families by promoting independence andcommunity responsibility; strengthening families;encouraging healthy behaviors; protecting vulnerablechildren, adults, and families; preventing individual andsocial problems; and providing services of value totaxpayers.

GGlossary of Common Terms

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32 Wisconsin Medicaid and BadgerCare � September 2003

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DHHSDepartment of Health and Human Services. The UnitedStates government’s principal agency for protecting thehealth of all Americans and providing essential humanservices, especially for those who are least able to helpthemselves.

The DHHS includes more than 300 programs, covering awide spectrum of activities, including overseeing Medicareand Medicaid; medical and social science research;preventing outbreak of infectious disease; assuring foodand drug safety; and providing financial assistance forlow-income families.

Emergency servicesThose services which are necessary to prevent death orserious impairment of the health of the individual. (For theMedicaid managed care definition of emergency, refer tothe Managed Care Guide or the Medicaid managed carecontract.)

EVSEligibility Verification System. Wisconsin Medicaidencourages all providers to verify eligibility beforerendering services, both to determine eligibility for thecurrent date and to discover any limitations to a recipient’scoverage. Providers may access recipient eligibilityinformation through the following methods:

• Automated Voice Response (AVR) System.• Magnetic stripe card readers.• Personal computer software.• Provider Services (telephone correspondents).• Direct Information Access Line with Updates for

Providers (Dial-Up).

Fee-for-serviceThe traditional health care payment system under whichphysicians and other providers receive a payment for eachunit of service provided rather than a capitation paymentfor each recipient.

Fiscal agentThe Department of Health and Family Services (DHFS)contracts with Electronic Data Systems (EDS) to providehealth claims processing services for Wisconsin Medicaid,including provider certification, claims payment, providerservices, and recipient services. The fiscal agent alsoissues identification cards to recipients, publishesinformation for providers and recipients, and maintains theWisconsin Medicaid Web site.

HCFAHealth Care Financing Administration. Please see thedefinition under CMS.

HCPCSHealthcare Procedure Coding System, formerly known as“HCFA Common Procedure Coding System.” A listing ofservices, procedures, and supplies offered by physiciansand other providers. HCPCS includes CurrentProcedural Terminology (CPT) codes, nationalalphanumeric codes, and local alphanumeric codes. Thenational codes are developed by the Centers for Medicareand Medicaid Services (CMS) to supplement CPT codes.

Maximum allowable fee scheduleA listing of all procedure codes allowed by WisconsinMedicaid for a provider type and Wisconsin Medicaid’smaximum allowable fee for each procedure code.

MedicaidMedicaid is a joint federal/state program established in1965 under Title XIX of the Social Security Act to pay formedical services for people with disabilities, people 65years and older, children and their caretakers, andpregnant women who meet the program’s financialrequirements.

The purpose of Medicaid is to provide reimbursement forand assure the availability of appropriate medical care topersons who meet the criteria for Medicaid. Medicaid isalso known as the Medical Assistance Program, Title XIX,or T19.

Glossary(Continued)

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Nurse Midwife Services Handbook � September 2003 33

Glossary

Medically necessaryAccording to HFS 101.03(96m), Wis. Admin. Code, aMedicaid service that is:

(a) Required to prevent, identify or treat a recipient’sillness, injury or disability; and

(b) Meets the following standards:1. Is consistent with the recipient’s symptoms or

with prevention, diagnosis or treatment of therecipient’s illness, injury or disability;

2. Is provided consistent with standards ofacceptable quality of care applicable to typeof service, the type of provider and the settingin which the service is provided;

3. Is appropriate with regard to generallyaccepted standards of medical practice;

4. Is not medically contraindicated with regardto the recipient’s diagnoses, the recipient’ssymptoms or other medically necessaryservices being provided to the recipient;

5. Is of proven medical value or usefulness and,consistent with s. HFS 107.035, is notexperimental in nature;

6. Is not duplicative with respect to other servicesbeing provided to the recipient;

7. Is not solely for the convenience of the recipient,the recipient’s family or a provider;

8. With respect to prior authorization of a serviceand to other prospective coveragedeterminations made by the department, is cost-effective compared to an alternative medicallynecessary service which is reasonablyaccessible to the recipient; and

9. Is the most appropriate supply or level of servicethat can safely and effectively be provided to therecipient.

Nurse MidwifeThe practice of nurse midwifery means the managementof women’s health care, pregnancy, childbirth, postpartumcare for newborns, family planning, and gynecologicalservices consistent with the standards of practice of theAmerican College of Nurse Midwives and the education,training, and experience of the nurse midwife. (Board ofNursing s. 441.15, Stats.)

Glossary(Continued)

Nurse PractitionerA nurse practitioner is a registered nurse with advancedacademic and clinical experience, which enables him orher to diagnose and manage most common and manychronic illnesses, either independently or as part of ahealth care team.

Medicaid-certified nurse practitioners who work under thegeneral supervision of a physician are required to besupervised only to the extent required pursuant to Board ofNursing Chapter N 6.02(7), Wis. Admin. Code. (ChapterN 6 defines general supervision as the regularcoordination, direction, and inspection of the practice ofanother and does not require the physician to be on site.)

On-site supervisionThe supervising physician is in the same building in whichservices are being provided and is immediately availablefor consultation or, in the case of emergencies, for directintervention.

POSPlace of service. A single-digit code which identifies theplace where the service was performed.

R/S ReportRemittance and Status Report. A statement generated bythe Medicaid fiscal agent to inform the provider regardingthe processing of the provider’s claims.

TOSType of service. A single-digit code which identifies thegeneral category of a procedure code.

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Nurse Midwife Services Handbook � September 2003 35

Index

IIndex

Allowable codes for nurse midwives,Procedure codes, 19, 21, 25Place of Service codes, 23Type of Service codes, 23

Certification, 5

Claim sample, 27

Covered services, 7

Obstetric services, 9

Maximum allowable fee, 8

Provider Numbers, 6

Newborn Care, 15Newborn Reporting, 15, 29Newborn Screenings, 16

ReimbursementEnhanced reimbursement, 8Maximum allowable fee, 8


Recommended