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Provider Manual

Surgery Information

Last Updated on August 20, 2021

Surgery Information

For detailed information, please see ForwardHealth Topic 656 ‘Surgical Procedures’ at  https://www.forwardhealth.wi.gov/WIPortal/.

  • Click  Online Handbooks
  • Click I Accept radio button and Submit Agreement
  • Under User Type, select Provider
  • Under Choose a program, select BadgerCare Plus and Medicaid
  • Under Choose a service area, select Physician
  • Select Reimbursement
  • Choose Amounts
  • Select Surgical Procedures

Multiple Surgery
Multiple surgical procedures performed by the same physician for the same member during the same surgical session are reimbursed at the following:

  • 100% of the maximum allowable fee for the primary procedure
  • 50% for the secondary procedure
  • 25% for the tertiary procedure
  • 13% for all subsequent procedures

The Medicaid-allowed surgery with the greatest usual and customary charge on the claim is reimbursed as the primary surgical procedure, the next highest is the secondary surgical procedure, etc.

Most diagnostic and certain vascular injection and radiological procedures are not subject to the multiple surgery reimbursement limits.

Bilateral Procedures
Bilateral surgical procedures are paid at 150 percent of the maximum allowable fee for the single service when a 50 modifier is allowable on the Medicaid Fee Schedule. Indicate modifier "50" (bilateral procedure) and a quantity of 1.0 on the claim.

Assistants at Surgery
Assistants at surgery are covered when the assistant is considered medically necessary and appropriate. Criteria considered include the need for the expertise of another surgeon in a complicated case for decision-making or surgical involvement.

Reimbursement for surgical assistance services is 20% of the reimbursement rate allowed for the provider type for the surgical procedure. To receive reimbursement for surgical assistance, indicate the surgery procedure code with the appropriate assistant surgeon modifier ("80," "81," "82," or "AS") on the claim.