HOME HEALTH/PERSONAL CARE (HHPC) 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 CO-PAYMENT PER VISIT. UNDER THE BADGERCARE PLUS BENCHMARK PLAN, FULL COVERAGE WILL BE PROVIDED FOR 60 HOME HEALTH VISITS PER ENROLLMENT YEAR PER MEMBER. COVERAGE FOR BADGERCARE PLUS BENCHMARK PLAN MEMBERS WILL BE THE SAME AS FOR BADGERCARE PLUS STANDARD PLAN MEMBERS WITH THE EXCEPTION THAT THE FOLLOWING SERVICES WILL NOT BE COVERED: PRIVATE DUTY NURSING AND PERSONAL CARE SERVICES. THIS REPORT HAS BEEN MODIFIED TO INCLUDE A BENCHMARK COLUMN TO INDICATE WHICH SERVICES ARE COVERED BENFITS FOR BENCHMARK PLAN MEMBERS. 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. 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.). BENCHMARK - INDICATES IF A PROCEDURE CODE IS A COVERED BENEFIT FOR BADGERCARE PLUS MEMBERS ENROLLED IN THE BENCHMARK PLAN. 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., NURSE SERVICE IS PROVIDER TYPE 33). TABLE I PROVIDER TYPES 33 - NURSE SERVICE 44 - Home Health 45 - NURSE PRACTITIONER 48 - HOME HEALTH/PERSONAL CARE DUALLY CERTIFIED PROVIDER 86 - PERSONAL CARE PROVIDER TABLE II PRICING ACTION CODES (PAC) 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 TABLE III MODIFIERS MODIFIER DESCRIPTION -------------- ---------------------------------------------------------------------------------------------------------- TE LICENSED PRACTICAL NURSE TD REGESTERED NURSE U1 CASE COORDINATION PROC DESCRIPTION PROC M1 M2 TM PROVIDER TYPE PAC EFFECT MAX FEE BENCH DATE MARK 92507 TREATMT OF SPEECH, LANGUAGE, VOICE, COMMUN, &/OR AUDITORY PROCSSING DISORDER; INDIVIDUAL 92507 44 48 270 10/01/03 85.35 Y 97139 UNLISTED PROCEDURE (SPECIFY) 97139 44 48 270 10/01/03 82.67 Y 97799 UNLISTED PHYSICAL MEDICINE SERVICE OR PROCEDURE 97799 44 48 270 10/01/03 80.52 Y 99504 HOME VISIT FOR PATIENTS RECEIVING MECHANICAL VENTILATOR 99504 TD 33 44 45 48 270 10/01/03 32.21 N 99504 TE 33 44 45 48 270 10/01/03 21.47 N 99504 U1 33 44 45 48 270 10/01/03 32.21 N 99509 HOME VISIT FOR ASSISTANCE W/ACTIVITIES OF DAILY LIVING & PERSONAL CARE 99509 48 86 270 10/01/03 41.56 N 99600 UNLISTED HOME VISIT SERVICE OR PROCEDURE 99600 44 45 48 270 10/01/03 84.28 Y 99600 UNLISTED HOME VISIT SERVICE OR PROCEDURE 99600 33 270 10/01/03 84.28 Y S9097 HOME VISIT FOR WOUND CARE S9097 44 45 48 86 220 10/01/04 N S9123 NURSING CARE, IN THE HOME; BY REGISTERED NURSE, PER HOUR S9123 33 44 45 48 270 10/01/03 32.21 N S9124 NURSING CARE, IN THE HOME; BY LICENSED PRACTICAL NURSE, PER HOUR S9124 33 44 48 270 10/01/03 21.47 N T1001 NURSING ASSESSMENT/EVALUATION T1001 44 48 270 10/01/03 84.28 Y T1019 PERS CARE SVCS, PER 15 MIN, NOT FOR INPATIENT, HOSPITAL, NURSING FACILITY, ICF/MR OR IMD T1019 48 86 270 10/01/03 3.96 N T1021 HOME HEALTH AIDE OR CERTIFIED NURSE ASSISTANT, PER VISIT T1021 44 48 270 10/01/03 39.71 Y T1502 ADMIN OF ORAL/INTRAMUSCULAR &/OR SUBCUTANEOUS MEDICATION, HLTH CARE AGENCY/PROF PER VISI T1502 33 44 45 48 270 10/01/03 39.71 Y END OF REPORT