Changes as a result of HIPAA

This Wisconsin Medicaid and BadgerCare Update introduces important billing changes for tuberculosis (TB)-related services. These changes will be implemented in October 2003 as a result of the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). A future Update will notify providers of the specific effective dates for the various changes. These changes are not policy or coverage related, but they include adopting nationally recognized procedure codes and place of service (POS) codes to replace currently used Wisconsin Medicaid local codes.

Note: Use of the newly adopted national codes prior to implementation dates may result in claim denials. Specific implementation dates will be published in a future Update.

Adoption of national codes

Wisconsin Medicaid will adopt nationally recognized medical codes to replace currently used Wisconsin Medicaid local codes for TB-related services. These codes will be for Wisconsin Medicaid recipients with TB and recipients eligible for the TB-related only services benefit.

Allowable procedure codes

Wisconsin Medicaid will adopt nationally recognized Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes to replace currently used Wisconsin Medicaid local procedure codes (W6271-W6276) for TB-related services. Refer to Attachment 1 of this Update for a procedure code conversion chart. Providers will be required to use the appropriate CPT or HCPCS procedure code that describes the service and level of service provided. Keep in mind that the maximum allowable fees listed in Attachment 1 are the proposed fees effective with the implementation of HIPAA, and may be subject to change. Wisconsin Medicaid will notify providers if the fees change from those printed in this Update.

Providers should continue to refer to the Guide to Tuberculosis-Related Services Only Benefit and to their service-specific Updates and handbooks for other nationally recognized procedure codes Wisconsin Medicaid covers.

Time units

When billing for a TB-related service with a CPT or HCPCS procedure code, a quantity of one will indicate a complete service. All TB-related services in Attachment 1 will have a limit of one quantity per day. Rates will be adjusted accordingly for the new time units.

Type of service codes

Type of service codes will no longer be required on Medicaid claims.

Place of service codes

Nationally recognized two-digit POS codes will replace the one-digit Wisconsin Medicaid POS codes. Refer to Attachment 2 for a list of allowable POS codes for TB-related services.

Coverage for tuberculosis-related services

Medicaid coverage, such as diagnosis restrictions, and documentation requirements for TB-related services remain unchanged. Refer to your service-specific handbook, the Guide to Tuberculosis-Related Services Only Benefit, and Updates for complete Medicaid policies and procedures.

General HIPAA information

Refer to the following Web sites for more HIPAA-related information:

• www.cms.gov/hipaa/ — Includes links to the latest HIPAA news and federal Centers for Medicare and Medicaid Services HIPAA-related links.
• aspe.hhs.gov/admnsimp/ — Contains links to proposed and final rules, links to download standards and HIPAA implementation guides, and frequently asked questions regarding HIPAA and the Administrative Simplification provisions.
• dhs.wisconsin.gov/hipaa/ — Contains Wisconsin Department of Health and Family Services HIPAA-related publications, a list of HIPAA acronyms, links to related Web sites, and other valuable HIPAA information.

Information regarding Medicaid HMOs

This Update contains Medicaid fee-for-service information and applies to providers of services to recipients who have fee-for-service Medicaid. Since HIPAA impacts all health care payers, it is important to know that HIPAA changes, including changes from local procedure codes to national procedure codes, will also have an impact on Medicaid HMOs. For questions related to Medicaid HMOs or managed care HIPAA-related changes, contact the appropriate managed care organization.

Attachment 1: Procedure code conversion chart for tuberculosis-related services.
Attachment 2: Place of service codes for tuberculosis-related services.