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Please see http://docs.legis.wisconsin.gov for the production version.
Alert! This chapter may be affected by an emergency rule:
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;
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;
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;
3. Bone marrow;
5. Heart-lung; and
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.
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.
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;
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.