Wisconsin Administrative Code
Department of Health Services
DHS 101-109 - Medical Assistance
Chapter DHS 107 - Covered Services
Section DHS 107.06 - Physician services

Universal Citation: WI Admin Code ยง DHS 107.06

Current through February 26, 2024

(1) COVERED SERVICES. Physician services covered by the MA program are, except as otherwise limited in this chapter, any medically necessary diagnostic, preventive, therapeutic, rehabilitative or palliative services provided in a physician's office, in a hospital, in a nursing home, in a recipient's residence or elsewhere, and performed by or under the direct supervision of a physician within the scope of the practice of medicine and surgery as defined in s. 448.01(9), Stats. These services shall be in conformity with generally accepted good medical practice.

(2) SERVICES REQUIRING PRIOR AUTHORIZATION. The following physician services require prior authorization in order to be covered under the MA program:

(a) All covered physician services if provided out-of-state under non-emergency circumstances by a provider who does not have border status. Transportation to and from these services shall also require prior authorization, which shall be obtained by the transportation provider;

(b) All medical, surgical, or psychiatric services aimed specifically at weight control or reduction, and procedures to reverse the result of these services;

(c) Surgical or other medical procedures of questionable medical necessity but deemed advisable in order to correct conditions that may reasonably be assumed to significantly interfere with a recipient's personal or social adjustment or employability, an example of which is cosmetic surgery;

(d) Prescriptions for those drugs listed in s. DHS 107.10 (2);

(e) Ligation of internal mammary arteries, unilateral or bilateral;

(f) Omentopexy for establishing collateral circulation in portal obstruction;

(g)
1. Kidney decapsulation, unilateral and bilateral;

2. Perirenal insufflation; and

3. Nephropexy: fixation or suspension of kidney (independent procedure), unilateral;

(h) Female circumcision;

(i) Hysterotomy, non-obstetrical or vaginal;

(j) Supracervical hysterectomy, that is, subtotal hysterectomy, with or without removal of tubes or ovaries or both tubes and ovaries;

(k) Uterine suspension, with or without presacral sympathectomy;

(l) Ligation of thyroid arteries as an independent procedure;

(m) Hypogastric or presacral neurectomy as an independent procedure;

(n)
1. Fascia lata by stripper when used as treatment for lower back pain;

2. Fascia lata by incision and area exposure, with removal of sheet, when used as treatment for lower back pain;

(o) Ligation of femoral vein, unilateral and bilateral, when used as treatment for post-phlebitic syndrome;

(p) Excision of carotid body tumor without excision of carotid artery, or with excision of carotid artery, when used as treatment for asthma;

(q) Sympathectomy, thoracolumbar or lumbar, unilateral or bilateral, when used as treatment for hypertension;

(r) Splanchnicectomy, unilateral or bilateral, when used as treatment for hypertension;

(s) Bronchoscopy with injection of contrast medium for bronchography or with injection of radioactive substance;

(t) Basal metabolic rate (BMR);

(u) Protein bound iodine (PBI);

(v) Ballistocardiogram;

(w) Icterus index;

(x) Phonocardiogram with interpretation and report, and with indirect carotid artery tracings or similar study;

(y)
1. Angiocardiography, utilizing C02 method, supervision and interpretation only;

2. Angiocardiography, either single plane, supervision and interpretation in conjunction with cineradiography or multi-plane, supervision and interpretation in conjunction with cineradiography;

(z)
1. Angiography - coronary: unilateral, selective injection, supervision and interpretation only, single view unless emergency;

2. Angiography - extremity: unilateral, supervision and interpretation only, single view unless emergency;

(za) Fabric wrapping of abdominal aneurysm;

(zb)
1. Mammoplasty, reduction or repositioning, one-stage - bilateral;

2. Mammoplasty, reduction or repositioning, two-stage - bilateral;

3. Mammoplasty augmentation, unilateral and bilateral;

4. Breast reconstruction and reduction.

(zc) Rhinoplasty;

(zd) Cingulotomy;

(ze) Dermabrasion;

(zf) Lipectomy;

(zg) Mandibular osteotomy;

(zh) Excision or surgical planning for rhinophyma;

(zi) Rhytidectomy;

(zj) Constructing an artificial vagina;

(zk) Repair blepharoptosis, lid retraction;

(zl) Any other procedure not identified in the physicians' "current procedural terminology", fourth edition, published by the American medical association;

Note: The referenced publication is on file and may be reviewed in the department's division of health care financing. Interested persons may obtain a copy by writing American Medical Association, 535 N. Dearborn Avenue, Chicago, Illinois 60610.

(zm) Transplants;
1. Heart;

2. Pancreas;

3. Bone marrow;

4. Liver;

5. Heart-lung; and

6. Lung.

Note: For more information about prior authorization, see s. DHS 107.02 (3).

(zn) Drugs identified by the department that are sometimes used to enhance the prospects of fertility in males or females, when proposed to be used for treatment of a non-fertility related condition;

(zo) Drugs identified by the department that are sometimes used to treat impotence, when proposed to be used for treatment of a non-impotence related condition;

(3) LIMITATIONS ON STERILIZATION.

(a) Conditions for coverage. Sterilization is covered only if:
1. The individual is at least 21 years old at the time consent is obtained;

2. The individual has not been declared mentally incompetent by a federal, state or local court of competent jurisdiction to consent to sterilization;

3. The individual has voluntarily given informed consent in accordance with all the requirements prescribed in subd. 4. and par. (d); and

4. At least 30 days, but not more than 180 days, have passed between the date of informed consent and the date of the sterilization, except in the case of premature delivery or emergency abdominal surgery. An individual may be sterilized at the time of a premature delivery or emergency abdominal surgery if at least 72 hours have passed since he or she gave informed consent for the sterilization. In the case of premature delivery, the informed consent must have been given at least 30 days before the expected date of delivery.

(b) Sterilization by hysterectomy.
1. A hysterectomy performed solely for the purpose of rendering an individual permanently incapable of reproducing or which would not have been performed except to render the individual permanently incapable of reproducing is a covered service only if:
a. The person who secured authorization to perform the hysterectomy has informed the individual and her representative, if any, orally and in writing, that the hysterectomy will render the individual permanently incapable of reproducing; and

b. The individual or her representative, if any, has signed and dated a written acknowledgment of receipt of that information prior to the hysterectomy being performed.

2. A hysterectomy may be a covered service if it is performed on an individual:
a. Already sterile prior to the hysterectomy and whose physician has provided written documentation, including a statement of the reason for sterility, with the claim form; or

b. Requiring a hysterectomy due to a life-threatening situation in which the physician determines that prior acknowledgment is not possible. The physician performing the operation shall provide written documentation, including a clear description of the nature of the emergency, with the claim form.

Note: Documentation may include an operative note, or the patient's medical history and report of physical examination conducted prior to the surgery.

3. If a hysterectomy was performed for a reason stated under subd. 1. or 2. during a period of the individual's retroactive eligibility for MA under s. DHS 103.08, the hysterectomy shall be covered if the physician who performed the hysterectomy certifies in writing that:
a. The individual was informed before the operation that the hysterectomy would make her permanently incapable of reproducing; or

b. The condition in subd. 2. was met. The physician shall supply the information specified in subd. 2.

(c) Documentation. Before reimbursement will be made for a sterilization or hysterectomy, the department shall be given documentation showing that the requirements of this subsection were met. This documentation shall include a consent form, an acknowledgment of receipt of hysterectomy information or a physician's certification form for a hysterectomy performed without prior acknowledgment of receipt of hysterectomy information.

Note: Copies of the consent form and the physician's certification form are reproduced in the Wisconsin medical assistance physician provider handbook.

(d) Informed consent. For purposes of this subsection, an individual has given informed consent only if all of the following occur:
1. The person who obtained consent for the sterilization procedure offered to answer any questions the individual to be sterilized may have had concerning the procedure, provided a copy of the consent form and provided orally all of the following information or advice to the individual to be sterilized:
a. Advice that the individual is free to withhold or withdraw consent to the procedure at any time before the sterilization without affecting the right to future care or treatment and without loss or withdrawal of any federally funded program benefits to which the individual might be otherwise entitled.

b. A description of available alternative methods of family planning and birth control.

c. Information that the sterilization procedure is considered to be irreversible.

d. A thorough explanation of the specific sterilization procedure to be performed.

e. A full description of the discomforts and risks that may accompany or follow the performing of the procedure, including an explanation of the type and possible effects of any anesthetic to be used.

f. A full description of the benefits or advantages that may be expected as a result of the sterilization.

g. Advice that the sterilization will not be performed for at least 30 days, except under the circumstances specified in par. (a) 4.

2. Suitable arrangements were made to ensure that the information specified in subd. 1. was effectively communicated to any individual who is blind, deaf, or otherwise disabled.

3. An interpreter was provided if the individual to be sterilized did not understand the language used on the consent form or the language used by the person obtaining consent.

4. The individual to be sterilized was permitted to have a witness of his or her choice present when consent was obtained.

5. The consent form requirements of par. (e) were met.

6. Any additional requirement of state or local law for obtaining consent, except a requirement for spousal consent, was followed.

7. Informed consent is not obtained while the individual to be sterilized is in any of the following situations:
a. In labor or childbirth.

b. Seeking to obtain or obtaining an abortion.

c. Under the influence of alcohol or other substances that affect the individual's state of awareness.

(e) Consent form.
1. Consent shall be registered on a form prescribed by the department.

Note: A copy of the informed consent form can be found in the Wisconsin medical assistance physician provider handbook.

2. The consent form shall be signed and dated by:
a. The individual to be sterilized;

b. The interpreter, if one is provided;

c. The person who obtains the consent; and

d. The physician who performs the sterilization procedure.

3. The person securing the consent and the physician performing the sterilization shall certify by signing the consent form that:
a. Before the individual to be sterilized signed the consent form, they advised the individual to be sterilized that no federally funded program benefits will be withdrawn because of the decision not to be sterilized;

b. They explained orally the requirements for informed consent as set forth on the consent form; and

c. To the best of their knowledge and belief, the individual to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized.

4.
a. Except in the case of premature delivery or emergency abdominal surgery, the physician shall further certify that at least 30 days have passed between the date of the individual's signature on the consent form and the date upon which the sterilization was performed, and that to the best of the physician's knowledge and belief, the individual appeared mentally competent and knowingly and voluntarily consented to be sterilized.

b. In the case of premature delivery or emergency abdominal surgery performed within 30 days of consent, the physician shall certify that the sterilization was performed less than 30 days but not less than 72 hours after informed consent was obtained because of premature delivery or emergency abdominal surgery. In the case of premature delivery, the physician shall state the expected date of delivery. In the case of abdominal surgery, the physician shall describe the emergency.

5. If an interpreter is provided, the interpreter shall certify that the information and advice presented orally was translated, that the consent form and its contents were explained to the individual to be sterilized and that to the best of the interpreter's knowledge and belief, the individual understood what the interpreter said.

(4) OTHER LIMITATIONS.

(a) Physician's visits. A maximum of one physician's visit per month to a recipient confined to a nursing home is covered unless the recipient has an acute condition which warrants more frequent care, in which case the recipient's medical record shall document the necessity of additional visits. The attending physician of a nursing home recipient, or the physician's assistant, or a nurse practitioner under the supervision of a physician, shall reevaluate the recipient's need for nursing home care in accordance with s. DHS 107.09 (4) (m).

(b) Services of a surgical assistant. The services of a surgical assistant are not covered for procedures which normally do not require assistance at surgery.

(c) Consultations. Certain consultations shall be covered if they are professional services furnished to a recipient by a second physician at the request of the attending physician. Consultations shall include a written report which becomes a part of the recipient's permanent medical record. The name of the attending physician shall be included on the consultant's claim for reimbursement. The following consultations are covered:
1. Consultation requiring limited physical examination and evaluation of a given system or systems;

2. Consultation requiring a history and direct patient confrontation by a psychiatrist;

3. Consultation requiring evaluation of frozen sections or pathological slides by a pathologist; and

4. Consultation involving evaluation of radiological studies or radiotherapy by a radiologist;

(cm) Interprofessional consultation. Interprofessional consultations shall be covered if all of the following apply:
1. The consultation is a professional service furnished to a recipient by a certified provider at the request of the treating provider.

2. The consultation constitutes an evaluation and management service in which the certified provider treating a recipient requests the opinion or treatment advice of a consulting provider with specific expertise to assist the treating provider in the evaluation or management of the recipients problem without requiring the recipient to have face-to-face contact with the consulting provider.

3. The consulting provider provides a written report that becomes a part of the recipient's permanent medical record.

(d) Foot care.
1. Services pertaining to the cleaning, trimming, and cutting of toenails, often referred to as palliative care, maintenance care, or debridement, shall be reimbursed no more than one time for each 31-day period and only if the recipient's condition is one or more of the following:
a. Diabetes mellitus;

b. Arteriosclerosis obliterans evidenced by claudication; or

c. Peripheral neuropathies involving the feet, which are associated with malnutrition or vitamin deficiency, carcinoma, diabetes mellitus, drugs and toxins, multiple sclerosis, uremia or cerebral palsy.

2. The cutting, cleaning and trimming of toenails, corns, callouses and bunions on multiple digits shall be reimbursed at one inclusive fee for each service which includes either one or both appendages.

3. For multiple surgical procedures performed on the foot on the same day, the physician shall be reimbursed for the first procedure at the full rate and the second and all subsequent procedures at a reduced rate as determined by the department.

4. Debridement of mycotic conditions and mycotic nails shall be a covered service in accordance with utilization guidelines established and published by the department.

5. The application of unna boots is allowed once every 2 weeks, with a maximum of 12 applications for each 12-month period.

(f) Services performed under a physician's supervision. Services performed under the supervision of a physician shall comply with federal and state regulations relating to supervision of covered services. Specific documentation of the services shall be included in the recipient's medical record.

(g) Dental services. Dental services performed by a physician shall be subject to all requirements for MA dental services described in s. DHS 107.07.

(h) Obesity-related procedures. Gastric bypass or gastric stapling for obesity is limited to medical emergencies, as determined by the department.

(i) Abortions.
1. Abortions, both surgically-induced and drug-induced, are limited to those that comply with s. 20.927, Stats.

2. Services, including drugs, directly related to non-surgical abortions shall comply with s. 20.927, Stats., may only be prescribed by a physician, and shall comply with MA policy and procedures as described in MA provider handbooks and bulletins.

(5) NON-COVERED SERVICES. The following services are not covered services:

(a) Services and items that are provided for the purpose of enhancing the prospects of fertility in males or females, within the meaning of s. DHS 107.03 (19).

(b) Abortions performed which do not comply with s. 20.927, Stats.;

(d) As separate charges, preoperative and postoperative surgical care, including office visits for suture and cast removal, which commonly are included in the payment of the surgical procedure;

(e) As separate charges, transportation expenses incurred by a physician, to include but not limited to mileage;

(f) Dab's and Wynn's solution;

(g) Except as provided in sub. (3) (b) 1., a hysterectomy if it was performed solely for the purpose of rendering an individual permanently incapable of reproducing or, if there was more than one purpose to the procedure, it would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing;

(h) Ear piercing;

(i) Electrolysis;

(j) Tattooing;

(k) Hair transplants;

(l) Vitamin C injections;

(m) Lincocin (lincomycin) injections performed on an outpatient basis;

(n) Orthopedic shoes and supportive devices such as arch supports, shoe inlays and pads;

(o) Services directed toward the care and correction of "flat feet";

(p) Sterilization of a mentally incompetent or institutionalized person, or of a person who is less than 21 years of age;

(q) Inpatient laboratory tests not ordered by a physician or other responsible practitioner, except in emergencies;

(r) Hospital care following admission on a Friday or Saturday, except for emergencies, accident care or obstetrical cases, unless the hospital can demonstrate to the satisfaction of the department that the hospital provides all of its services 7 days a week;

(s) Liver injections;

(t) Acupuncture;

(u) Phonocardiogram with interpretation and report;

(v) Vector cardiogram;

(w) Non-emergency gastric bypass or gastric stapling for obesity; and

(x) Separate charges for pump technician services.

For more information on non-covered services, see s. DHS 107.03.

Disclaimer: These regulations may not be the most recent version. Wisconsin may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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