• Provider Information
  • Introduction
  • Scope of Services
  • Services Provided by Registered Nurses
    • Introduction
    • Supervision of Delegated Tasks
  • Services Provided by Licensed Practical Nurses
  • Classification of Nursing Services
  • Wisconsin Medicaid Certification Requirements
  • Requirements for Providing Ventilator-Dependent Services
    • Introduction
    • Demonstration Renewals
    • Age-Specific Requirements
  • Changes in Certification
• Rights and Responsibilities
  • Introduction
  • Universal Precautions
  • Unacceptable Practices
  • Fees Prohibited by Wisconsin Medicaid
  • Private Duty Nursing Requirements
  • Emergency and Back-Up Procedures
  • Verifying Recipient Eligibility
    • Introduction
    • Limited Benefit Categories
  • Distribution of Medicaid Information
  • Written Statement of Recipient Rights
  • Contracts with Recipient and/or Family
  • Terminating Service to a Recipient
  • Recipient Responsibilities
    • Arrangements with Nurses in Independent Practice
    • Scheduling Providers
    • Freedom from Liability for Covered Services
• Covered Services and Related Limitations
  • Introduction
  • Private Duty Nursing Benefit
  • Recipient Eligibility for Private Duty Nursing Services
    • Introduction
    • Ventilator-Dependent Recipients
    • Recipients Who Are Not Eligible for Private Duty Nursing Services
  • Hours of Care That Qualify as Private Duty Nursing Services
  • Private Duty Nursing Services Reimbursement Requirements
  • Place of Service for Private Duty Nursing Recipients
  • Providing Disposable Medical Supplies
  • Coordination Services for Ventilator-Dependent Recipients
    • Introduction
    • Documenting Coordination Services
    • Reimbursable Coordination Responsibilities
    • Change in Coordinators
  • Coordination Services for Recipients Not Ventilator-Dependent
    • Introduction
    • Coordination Services Documentation
    • Coordination Responsibilities
    • Change in Coordinators
  • Case Sharing
    • Introduction
    • Provider Responsibility
    • Case Sharing Documentation
  • Reimbursement Not Available
    • Introduction
    • Travel and Record-Keeping Time
• Documentation Requirements
  • Introduction
  • Required Information for Medical Record
    • Introduction
    • Physician Signature
  • Documentation Requirements of Supervising Nurses
  • Availability of Records to Others
    • Introduction
    • Record Maintenance After Termination as Wisconsin Medicaid Provider
• Plan of Care
  • Introduction
  • Plan of Care Documentation Methods
    • Introduction
    • Submitting Another Format for the Recipient's Plan of Care
  • Obtaining Plan of Care Forms
  • Developing the Plan of Care
  • Physician's Orders and Signature
    • Introduction
    • Start of Care
    • Certification Period
    • Verbal Orders
  • Plan of Care Requirements
  • Medical Necessity and the Plan of Care
  • Changes to the Plan of Care
• Prior Authorization
  • Introduction
  • Responsibility for Prior Authorization
  • Services Requiring Prior Authorization
    • Introduction
    • Limits on Authorized Services
  • Requesting Private Duty Nursing Hours
    • Introduction
    • Hours of Private Duty Nursing for Children
    • Requesting Pro Re Nata Hours
    • Flexible Use of Weekly Hours
  • Required Documentation for Prior Authorization Requests
    • Introduction
    • Prior Authorization Request Form
    • Private Duty Nursing Prior Authorization Acknowledgment
    • Prior Authorization Attachments
  • Submitting Prior Authorization Requests
  • Prior Authorization Effective Dates
  • Prior Authorization Responses
  • Prior Authorization Backdating
    • Introduction
    • Initial Requests
    • Extraordinary Circumstances
    • Subsequent Requests Will Not Be Backdated
    • Returned Requests
    • Amendment Requests
    • Denied Requests
  • Amending an Approved or Modified Prior Authorization Request
  • Enddating a Prior Authorization Request
  • Out-of-State Private Duty Nursing
    • Introduction
    • Out-of-State Prior Authorization Request Requirements
    • Procedure for Obtaining Authorization for Out-of-State Travel
• Claims Submission
  • Introduction
  • Claims Submission Options
    • Introduction
    • Paper Claims Submission
  • Follow-Up to Claims Submission
  • Billing Across Midnight
  • Daylight Savings Time
• Codes for Prior Authorization and Claims
  • Introduction
  • Revenue Codes
  • Date of Service
  • Procedure Codes
  • Modifiers
    • Introduction
    • Start-of-Shift Modifiers
    • Professional Status Modifiers
    • Case Coordination Modifier
  • Units of Service
    • Introduction
    • Rounding Guidelines
  • Prior Authorization Number
  • Diagnosis Code
• Appendix
• PDF

 

 

DATE:	October 17, 2005
TO:	Wisconsin Medicaid Nurses in Independent Practice, HMOs, and other Managed Care Organizations
FROM:	Mark B. Moody, Administrator Division of Health Care Financing
SUBJECT:	Introducing the Wisconsin Medicaid Nurses in Independent Practice Handbook

The Division of Health Care Financing (DHCF) is pleased to provide you with a copy of the Nurses in Independent Practice Handbook. This handbook is a guide to Wisconsin Medicaid for all Medicaid-certified nurses in independent practice. Providers should maintain and refer to this handbook in conjunction with the All-Provider Handbook.

The handbook incorporates current Wisconsin Medicaid policies related to nurses in independent practice into a single reference source. The handbook replaces the following service specific Wisconsin Medicaid and BadgerCare Updates:

• August 2005 Update (2005-57), Wisconsin Medicaid Issues Prior Authorization home Care Attachment for Home Health and Private Duty Nursing Services.
• May 2005 Update (2005-27), Change in Requirements for Retaining Certification to Provide Private-Duty Nursing Services After Certification to Provide Respiratory Care Expires.
• March 2005 Update (2005-14), Registered Nurses Required to Use Modifier "U1" for Coordinating Services of Ventilator-Dependent Recipients.
• February 2004 Update (2004-08), Submitting claims with start-of-shift modifiers for homecare services.
• August 2003 Update (2003-81), Changes to local codes, paper claims, and prior authorization for private duty nursing and respiratory care services of nurses in independent practice as a result of HIPAA.
• April 1999 Update (99-13), Wisconsin Medicaid revises private duty nursing prior authorization guideline
• June 1996 Update (96-19), RCS and private duty nursing services: clarification of administrative and case coordination responsibilities.
• October 1995 Update (95-36), Home health changes for medication management.
• January 1995 Update (95-2), New HCFA-485/486 forms

Providers should retain and continue to refer to the following Updates; the handbook does not replace them:

• April 2005 Update (2005-21), Providers Will No Longer Routinely Receive Paper Copies of Wisconsin Medicaid and BadgerCare Updates.
• February 2005 Update (2005-11), Wisconsin Medicaid Accepts Physicians' Stamped Signatures from Home Care and Hospice Providers.
• February 2005 Update (2005-08), Wisconsin Medicaid Accepting Prior Authorization Requests Via the Web for Additional Service Areas.
• January 2005 Update (2005-03), Procedure Code Updates for Disposable Medical Supplies.
• December 2004 Update (2004-89), Wisconsin Medicaid Accepting Prior Authorization Requests Via the Medicaid Web Site for Additional Service Areas; Training Sessions in January and February 2005.
• February 2004 Update (2004-04), Procedure code updates for disposable medical supplies.
• December 2003 Update (2003-164), Copayment for disposable medical supplies.
• July 2003 Update (2003-51), Changes to local codes, paper claims, and prior authorization for disposable medical supplies as a result of HIPAA.

This handbook does not replace all-provider publications, The Wisconsin Administrative Code or Wisconsin Statues. Subsequent changes to policies affecting nurses in independent practice will be published first in Updates and later in Nurses in Independent Practice Handbook revisions.

Additional Copies of Publications

The Wisconsin Medicaid Web site, dhs.wisconsin.gov/medicaid/, contains additional information for nurses in independent practice, all Updates and electronic versions of the Nurses in Independent Practice Handbook and the All-Provider Handbook.

Providers who have questions about the information in this handbook may call Provider Services at (800) 947-9627 or (608) 221-9883.

The DHFS would like to thank representatives from Professional Homecare Providers and the independent nursing industry for reviewing this handbook.

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Nurses in Independent Practice
March 2006