CHIROPRACTOR MAXIMUM ALLOWABLE FEE SCHEDULE THIS IS YOUR WISCONSIN MEDICAID MAXIMUM ALLOWABLE FEE SCHEDULE, WHICH IS IN EFFECT AS OF THE DATE OF THIS REPORT. WISCONSIN MEDICAID CERTIFIED PROVIDERS WILL BE REIMBURSED FOR SERVICES PROVIDED TO PROGRAM RECIPIENTS AT THE LOWER OF THEIR USUAL AND CUSTOMARY CHARGE, OR THE MAXIMUM ALLOWABLE FEE. SERVICES REIMBURSED BASED ON PROVIDER SPECIFIC (CONTRACTED RATES) AND REGIONAL OR SPECIALTY BASED RATES ARE NOT INCLUDED IN THIS FEE SCHEDULE. NOTE: BADGERCARE PLUS BENCHMARK PLAN MEMBERS WILL BE RESPONSIBLE FOR A $15.00 COPAYMENT PER VISIT. A SINGLE COPAYMENT OF $15.00 IS ASSESSED PER VISIT, REGARDLESS OF THE NUMBER OF SERVICES PROVIDED DURING THAT VISIT. ALTHOUGH THE FEE SCHEDULE DOES NOT ADDRESS THE VARIOUS COVERAGE LIMITATIONS ROUTINELY APPLIED BY WISCONSIN MEDICAID BEFORE FINAL PAYMENT IS DETERMINED (E.G., RECIPIENT AND PROVIDER ELIGIBILITY, BILLING INSTRUCTIONS, FREQUENCY OF SERVICES, THIRD PARTY LIABILITY, COPAYMENT, AGE RESTRICTIONS, PRIOR AUTHORIZATION, ETC.), IT DOES CONTAIN THE FOLLOWING INFORMATION: PROC/M1/M2/TM PROC - THE PROCEDURE CODE RECOGNIZED BY WISCONSIN MEDICAID TO IDENTIFY THE SERVICE PROVIDED. M1/M2 - ONE OR TWO APPLICABLE MODIFIER(S) AFFECTING REIMBURSEMENT AMOUNT. NOTE: CURRENTLY THERE ARE NO MODIFIERS AFFECTING REIMBURSEMENT ASSOCIATED WITH CHIROPRACTIC PROCEDURES. TM - DESCRIPTIVE MODIFIER USED TO CONVEY INFORMATION FORMERLY CONVEYED BY TOS. NOTE: IN CERTAIN INSTANCES THE MODIFIER LISTED IS BEING USED BOTH TO CONVEY INFORMATION FORMERLY CONVEYED BY TOS AND TO AFFECT THE REIMBURSEMENT AMOUNT. IN THESE INSTANCES THE MODIFIER WILL BE DISPLAYED TWICE, ONCE IN THE M1 OR M2 COLUMN AND ONCE IN THE TM COLUMN, EVEN THOUGH IT WILL ONLY BE BILLED ONCE ON THE CLAIM DETAIL. DESCRIPTION - AN ABBREVIATED DESCRIPTION OF THE PROCEDURE CODE PROVIDER TYPE - ALL APPLICABLE PERFORMING PROVIDER TYPES FOR THE PROCEDURE CODE. SEE TABLE I FOR A LISTING OF PROVIDER TYPES APPLICABLE TO THIS SCHEDULE. PAC - THE PRICING ACTION CODE IDENTIFIES NON-COVERED SERVICES OR THE SOURCE AND METHOD OF PRICING THE PROCEDURE (REFER TO TABLE II). EFFECT DATE - THE EFFECTIVE DATE OF SERVICE ON OR AFTER WHICH THE MAXIMUM ALLOWABLE FEE APPLIES. MAX FEE - MAXIMUM ALLOWABLE FEES FOR THE PROCEDURE CODES LISTED. IF A MAX FEE IS NOT INDICATED, USE THE PAC AND TABLE II TO DETERMINE THE REASON (E.G., PAC 220 INDICATES SERVICE NOT COVERED; PAC 21J INDICATES INDIVIDUAL CONSIDERATION, ETC.). THIS INFORMATION IS INTENDED TO HELP YOU UNDERSTAND THE WISCONSIN MEDICAID MAXIMUM ALLOWABLE FEE SCHEDULE. IF YOU HAVE QUESTIONS, PLEASE CONTACT WISCONSIN MEDICAID PROVIDER SERVICES AT: (608) 221-9883 OR (800) 947-9627* *WHEN REQUESTING INFORMATION, PLEASE BE SPECIFIC AS TO WHICH PROVIDER TYPE YOU ARE REFERRING (I.E., CHIROPRACTORS ARE PROVIDER TYPE 30). TABLE I PROVIDER TYPES 30 - CHIROPRACTOR TABLE II PRICING ACTION CODES (PAC) 11J, 21J - INDIVIDUAL CONSIDERATION, MEDICAL CONSULTANT 120, 220 - NON-COVERED SERVICE, NOT A WISCONSIN MEDICAID BENEFIT 170, 270 - PAID AT THE LOWER OF THE BILLED AMOUNT OR MAXIMUM ALLOWABLE FEE ACCORDING TO PROVIDER TYPE 279 - REVIEW OF SERVICE, REPORT DETERMINES COVERAGE AND/OR REIMBURSEMENT. TABLE III MODIFIERS MODIFIER DESCRIPTION -------------- ---------------------------------------------------------------------------------- CURRENTLY THERE ARE NO MODIFIERS AFFECTING REIMBURSEMENT ASSOCIATED WITH CHIROPRACTIC PROCEDURES. PROC DESCRIPTION PROC M1 M2 TM PROVIDER TYPE PAC EFFECT MAX FEE DATE 72010 RADIOLOGIC EXAMINATION/ SPINE/ ENTIRE SURVEY STUDY/ ANTEROPOSTERIOR AND LATRERAL 72010 30 279 07/01/02 56.85 72020 RADIOLOGIC EXAMINATION/SPINE/SINGLE VIEW 72020 30 279 07/01/02 24.06 72040 RADIOLOGIC EXAMINATION, SPINE, CERVICAL; TWO OR THREE VIEWS 72040 30 279 07/01/02 29.71 72050 RADIOLOGIC EXAMIMATIOM/ SPINE/ CERVICAL; MINIMUM OF FOUR VIEWS 72050 30 279 07/01/02 33.05 72052 RADIOLOGIC EXAMINATION / SPINE/ CERVICAL; COMPLETE 72052 30 279 07/01/02 47.36 72070 RADIOLOGIC EXAMINATION, SPINE; THORACIC, TWO VIEWS 72070 30 279 07/01/02 29.71 72100 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO OR THREE VIEWS 72100 30 279 07/01/02 29.71 72110 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF FOUR VIEWS 72110 30 279 07/01/02 47.36 72120 RADIOLOGIC EXAMINATION/ SPINE/ LUMBOSACRAL/ BENDING VIEWS 72120 30 279 07/01/02 33.05 72200 RADIOLOGIC EXAMINATION/ SACROILIAC JOINTS/ LESS THAN THREE VIEWS 72200 30 279 07/01/02 26.25 72202 RADIOLOGIC EXAMINATION/ SACROILIAC JOINTS; THREE OR MORE VIEWS 72202 30 279 07/01/02 31.57 72220 RADIOLOGIC EXAMINATION/ SACRUM AND COCCYX/ MINIMUM OF TWO 72220 30 279 07/01/02 29.71 73000 RADIOLOGIC EXAMINATION/ CLAVICLE/ COMPLETE 73000 30 279 07/01/02 20.36 73010 RADIOLOGIC EXAMINATION; SCAPULA/ COMPLETE 73010 30 279 07/01/02 29.71 73020 RADIOLOGIC EXAMINATION/ SHOULDER; ONE VIEW 73020 30 279 07/01/02 15.77 73030 RADIOLOGIC EXAMINATION/ SHOULDER; COMPLETE/ MINIMUM OF TWO VIEWS 73030 30 279 07/01/02 29.71 73050 RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS/ BILATERAL W/WO WEIGHTED DISTRACTION 73050 30 279 07/01/02 27.64 73060 RADIOLOGIC EXAMINATION; HUMERUS/ MINIMUM OF TWO VIEWS 73060 30 279 07/01/02 20.36 73070 RADIOLOGIC EXAMINATION, ELBOW; TWO VIEWS 73070 30 279 07/01/02 20.36 73080 RADIOLOGIC EXAMINATION/ ELBOW; COMPLETE/ MINIMUM OF THREE VIEWS 73080 30 279 07/01/02 26.25 73500 RADIOLOGIC EXAMINATION/ HIP; UNILATERAL/ ONE VIEW 73500 30 279 07/01/02 26.25 73510 RADIOLOGIC EXAMINATION/ HIP; COMPLETE/ MINIMUM OF TWO VIEWS 73510 30 279 07/01/02 33.05 73520 RADIOLOGIC EXAMINATION/ HIPS/ BILATERAL/ MINIMUM OF TWO VIEWS 73520 30 279 07/01/02 39.47 73540 RADIOLOGIC EXAMINATION/ PELVIS AND HIPS/ INFANT OR CHILD/ MINIMUM OF TWO VIEWS 73540 30 279 07/01/02 29.71 73550 RADIOLOGIC EXAMINATION, FEMUR, TWO VIEWS 73550 30 279 07/01/02 29.71 73560 RADIOLOGIC EXAMINATION, KNEE; ONE OR TWO VIEWS 73560 30 279 07/01/02 20.36 73562 RADIOLOGIC EXAMINATION, KNEE; THREE VIEWS 73562 30 279 07/01/02 26.26 73564 RADIOLOGIC EXAM KNEE; COMPLETE, FOUR OR MORE VIEWS 73564 30 279 07/01/02 24.49 81000 UNRINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES 81000 30 279 07/01/02 4.37 98940 CHIROPRACTIC MANIPULATIVE TREATMENT (CMT);SPINAL ONE TO TWO REGIONS 98940 30 270 07/01/02 17.31 98941 CHIROPRACTIC MANIPULATIVE TREATMENT (CMT)SPINAL, THREE TO FOUR REGIONS 98941 30 270 07/01/02 23.90 98942 CHIROPRACTIC MANIPULATIVE TREATMENT;(CMT);SPINAL, FIVE REGIONS 98942 30 270 07/01/02 30.97 99201 OFFICE/OP VISIT-NEW PATIENT: PROB-FOCUSED HIST/EXAM & STRAIGHT MED DECISION (10 MIN) 99201 30 270 07/01/02 19.60 L0120 CERVICAL, FLEXIBLE, NON-ADJUSTABLE (FOAM COLLAR) L0120 30 170 10/01/03 15.76 L0140 CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTIC COLLAR) L0140 30 170 10/01/03 33.40 L0210 THORACIC, RIB BELT L0210 30 170 10/01/03 10.70 END OF REPORT