HEALTH CHECK 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 COVERED FOR HEALTHCHECK SERVICES. COVERAGE FOR BADGERCARE PLUS BENCHMARK MEMBERS WILL BE THE SAME AS BADGERCARE PLUS STANDARD MEMBERS WITH THE EXCEPTION THAT THE FOLLOWING SERVICES WILL NOT BE COVERED: HEALTHCHECK OTHER SERVICES, INTERPERIODIC VISITS, INTENSIVE IN-HOME TREATMENT, AND RESIDENTIAL CARE CENTER. 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 CONVEYEDBY 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 COLUMNAND 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. HEALTH CHECK (EPSDT)). TABLE I PROVIDER TYPES 66 – HEALTH CHECK (EPSDT) 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 TABLE III MODIFIERS MODIFIER DESCRIPTION -------------- ----------------------------------------------------------------- QW CLIA WAIVED SERVICES TS FOLLOW UP SERVICE (FOR LEAD INSPECTION) EP SERVICES PROVIDED AS PART OF MEDICAID EARLY PERIODIC SCREENING DIAGNOSIS And TREATMENT (EPSDT) PROGRAM PROC DESCRIPTION PROC M1 M2 TM PROVIDER TYPE PAC EFFECT MAX FEE BENCH DATE MARK 81002 URINALYSIS, BY DIP STICK OR TABLET REAGENT; WITHOUT MICROSCOPY, NON-AUTOMATED 81002 66 270 01/01/98 3.54 Y 81025 URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS 81025 66 270 01/01/98 8.74 Y 82465 CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL 82465 66 270 01/01/98 6.02 Y 82465 QW 66 270 07/01/01 6.02 Y 82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP) 82947 66 270 01/01/98 5.42 Y 82947 QW 66 270 01/01/98 5.42 Y 83655 LEAD 83655 66 270 01/01/98 16.72 Y 85013 BLOOD COUNT; SPUN MICR0HEMATOCRIT 85013 66 270 01/01/98 3.27 Y 85018 BLOOD COUNT; HEMOGLOBIN (HGB) 85018 66 270 01/01/98 3.27 Y 85018 QW 66 270 07/01/01 3.27 Y 86580 SKIN TEST; TUBERCULOSIS/ INTRADERMAL 86580 66 270 10/01/03 9.21 Y 90632 HEPATITIS A VACCINE, ADULT DOSAGE, FOR INTRAMUSCULAR USE 90632 66 21J 01/01/99 Y 90633 HEPATITIS A VACCINE, PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE SCHEDULE, FOR INTRAMUSCULAR USE 90633 66 270 02/01/07 3.28 Y 90636 HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT DOSAGE, FOR INTRAMUSCULAR USE 90636 66 270 12/14/06 91.72 Y 90645 HEMOPHILUS INFLUENZA B VACCINE,HBOC CONJUGATE(4 DOSE SCHEDULE),FOR INTRAMUSCULAR USE 90645 66 270 08/15/05 3.28 Y 90647 HEMOPHILUS INFLUENZA B VACCINE,PRP-OMP CONJUGATE(3 DOSE SCHEDULE),FOR INTRAMUSCULAR USE 90647 66 270 08/15/05 3.28 Y 90648 HEMOPHILUS INFLUENZA B VACCINE, PRP-T CONJUGATE (4 DOSE SCHEDULE), FOR INTRAMUSCULAR USE 90648 66 270 08/15/05 3.28 Y 90655 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, WHEN ADMIN TO CHILD 6-35 MOS 90655 66 270 09/01/04 3.28 Y 90656 INFLUENZA VIRUS VAC,SPLIT VIRUS,PRESERVATIVE FREE,ADM TO INDIVIDUALS 3 YRS AGE AND OLDER 90656 66 270 02/01/07 3.28 Y 90657 INFLUENZA VIRUS VACCINE,SPLIT VIRUS,WHEN ADMIN TO CHILD 6-35 MOS, FOR INTRAMUSCULAR USE 90657 66 270 09/01/04 3.28 Y 90658 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMIN TO 3 YRS & OLDER, FOR INTRAMUSCULAR USE 90658 66 270 02/01/07 3.28 Y 90660 INFLUENZA VIRUS VACCINE, LIVE, FOR INTRANASAL USE 90660 66 270 02/01/07 3.28 Y 90669 PNEUMOCOCCAL CONJUGATE VACCINE, POLYVALENT, WHEN ADMIN TO CHILDREN YOUNGER THAN 5 YRS 90669 66 270 08/15/05 3.28 Y 90700 DIPHTHERIA, TETANUS TOXOIDS & ACELLULAR PERTUSSIS VAC, ADMIN TO INDIV YOUNGER THAN 7 YRS 90700 66 270 07/01/02 3.28 Y 90701 DIPTHERIA, TETANUS TOXOIDS, & WHOLE CELL PERTUSSIS VACCINE (DTP), FOR INTRAMUSCULAR USE 90701 66 220 08/01/05 N 90702 DIPHTHERIA & TETANUS TOXOIDS (DT) ADSORBED WHEN ADMIN TO INDIV YOUNGER THAN 7 YRS,INTRAM 90702 66 270 08/15/05 3.28 Y 90707 MEASLES, MUMPS, AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR SUBCUTANEOUS USE 90707 66 270 07/01/02 3.28 Y 90713 POLIOVIRUS VACCINE, INACTIVATED (IPV), FOR SUBCUTANEOUS OR INTRAMUSCULAR USE 90713 66 270 07/01/02 3.28 Y 90716 VARICELLA VIRUS VACCINE, LIVE, FOR SUBCUTANEOUS USE 90716 66 270 08/15/05 3.28 Y 90718 TETANUS & DIPHTHERIA TOXOIDS ADSORBED WHEN ADMIN TO INDIV 7 YRS/OLDER,FOR INTRAMUSC USE 90718 66 270 04/01/05 3.28 Y 90723 DIPHTHERIA,TETANUS TOXOIDS,ACELLULAR PERTUSSIS,HEPATITIS B & POLIOVIRUS VAC,INACTIVATED, 90723 66 270 04/01/03 3.28 Y 90732 PNEUMOCOCCAL POLYSACCHARIDE VAC,23-VALENT,ADULT OR IMMUNOSUPPRESSED PAT DOSAGE,2 YRS/> 90732 66 270 08/15/05 20.19 Y 90734 MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A,C,Y & W-135, FOR INTRAMUSCULAR USE 90734 66 270 09/01/05 3.28 Y 90740 HEPATITIS B VAC,DIALYSIS OR IMMUNOSUPPRESED PAT DSGE,(3 DOSE SCHDEULE),INTRAMUSCULAR USE 90740 66 270 04/01/07 114.52 Y 90743 HEPATITIS B VACCINE, ADOLESCENT (2 DOSE SCHEDULE), FOR INTRAMUSCULAR USE 90743 66 270 07/01/02 63.07 Y 90744 HEPATITUS B VACCINE, PEDIATRIC/ADOLESCENT DOSAGE (3 DOSE SCHEDULE),FOR INTRAMUSCULAR USE 90744 66 270 08/15/05 3.28 Y 90746 HEPATITIS B VACCINE, ADULT DOSAGE, FOR INTRAMUSCULAR USE 90746 66 270 01/01/07 60.54 Y 90747 HEPATITIS B VACCINE,DIALYSIS OR IMMUNOSUPPRESSED PAT DOSAGE (4 DOSE SCHEDULE),INTRAMUSCU 90747 66 270 08/15/05 3.28 Y 90748 HEPATITIS B AND HEMOPHILUS INFLUENZA BVAC CINE (HEPB-HIB), FOR INTRAMUSCULAR USE 90748 66 270 08/15/05 3.28 Y 90749 UNLISTED VACCINE/TOXOID 90749 66 21J 07/01/92 Y 99000 HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE PHYSICIAN'S OFFICE TO A LAB 99000 66 270 07/01/02 3.88 Y 99211 OFFICE/OP VISIT-ESTABLISHED PATIENT (5 MINUTES) 99211 66 270 10/01/03 10.85 N 99212 OFFICE/OP VISIT-ESTABLISHED PATIENT (10 MINUTES) 99212 66 270 10/01/03 10.85 N 99213 OFFICE/OP VISIT-ESTABLISHED PATIENT (15 MINUTES) 99213 66 270 10/01/03 16.27 N 99214 OFFICE/OP VISIT-ESTABLISHED PATIENT (25 MINUTES) 99214 66 270 10/01/03 16.27 N 99215 OFFICE/OP VISIT-ESTABLISHED PATIENT (40) MINUTES 99215 66 270 10/01/03 27.11 N 99381 INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVAL & MANAGEMENT OF AN INDIVIDUAL INCL AGE 99381 66 270 10/01/03 55.31 Y 99382 INITIAL EVAL/MGMT- EARLY CHILDHOOD INDIVIDUAL (AGE 1 THROUGH 4 YEARS) 99382 66 270 10/01/03 55.31 Y 99383 INITIAL EVAL/MGMT- LATE CHILDHOOD INDIVIDUAL (AGE 5 THROUGH 11 YEARS) 99383 66 270 10/01/03 55.31 Y 99384 INITIAL EVAL/MGMT- ADOLESCENT INDIVIDUAL (AGE 12 THROUGH 17 YEARS) 99384 66 270 10/01/03 55.31 Y 99385 INITIAL EVAL/MGMT- 18-39 YEAR OLD INDIVIDUALS 99385 66 270 10/01/03 55.31 Y 99391 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION & MANAGEMENT OF AN INDIVIDUAL IN 99391 66 270 10/01/03 55.31 Y 99392 PERIODIC REEVAL/MGMT- EARLY CHILDHOOD INDIVIDUAL (AGE 1 THROUGH 4 YEARS) 99392 66 270 10/01/03 55.31 Y 99393 PERIODIC REEVAL/MGMT- LATE CHILDHOOD INDIVIDUAL (AGE 5 THROUGH 11 YEARS) 99393 66 270 10/01/03 55.31 Y 99394 PERIODIC REEVAL/MGMT- ADOLESCENT INDIVIDUAL (AGE 12 THROUGH 17 YEARS) 99394 66 270 10/01/03 55.31 Y 99395 PERIODIC REEVAL/MGMT- 18 - 39 YEAR OLD INDIVIDUALS 99395 66 270 10/01/03 55.31 Y 99401 PREVENTIVE MEDICINE COUNSELING &/OR RISK FACTOR REDUCTION INTERVENTION TO INDIVID-15 MIN 99401 66 270 10/01/03 9.39 Y 99402 PREVENTIVE MEDICINE COUNSELING &/OR RISK FACTOR REDUCTION INTERVENTION TO INDIVID-30 MIN 99402 66 270 10/01/03 18.78 Y 99403 PREVENTIVE MEDICINE COUNSELING &/OR RISK FACTOR REDUCTION INTERVENTION TO INDIVID-45 MIN 99403 66 270 10/01/03 28.18 Y 99404 PREVENTIVE MEDICINE COUNSELING &/OR RISK FACTOR REDUCTION INTERVENTION TO INDIVID-60 MIN 99404 66 270 10/01/03 37.57 Y D1203 TOP FLUORIDE - CHILD/00-12 (EXCLUDING PROPHYLAXIS) D1203 66 270 02/26/04 12.76 Y S9445 PATIENT EDUCATION, NOT OTHERWISE CLASSIFIED, NON-PHYSICIAN PROVIDER, INDIVIDUAL, PER SES S9445 66 270 10/01/03 37.57 Y T1002 RN SERVICES, UP TO 15 MINUTES T1002 EP 66 270 10/01/03 6.78 N T1016 CASE MANAGEMENT, EACH 15 MINUTES T1016 EP 66 270 10/01/03 4.55 Y T1017 TARGETED CASE MANAGEMENT, EACH 15 MINUTES T1017 EP 66 270 10/01/03 7.46 Y T1029 COMPREHENSIVE ENVIRONMENTAL LEAD INVESTIGATION, NOT INCLUDING LAB ANALYSIS, PER DWELLING T1029 EP 66 270 10/11/03 105.26 N T1029 TS EP 66 270 10/11/03 52.63 N END OF REPORT