Lead-Safe Wisconsin: Medicaid Reimbursement for Lead-Related Services
HealthCheck providers can bill Medicaid for lead-related services in certain circumstances. They can email the Childhood Lead Poisoning Prevention Program (CLPPP) at DHSLeadPoisoningPrevention@dhs.wisconsin.gov to find the current reimbursement rates. The CLPPP provides resources to help local health departments, providers, and community groups prevent, detect, and treat childhood lead poisoning.
There are also Medicaid provider field representatives in each region who can help with Medicaid-specific questions.
- Watch the webinar presented by the CLPPP on Medicaid reimbursement for lead-related services:
- Read the March 2018 ForwardHealth Update, “New Coverage Policy Regarding Environmental Lead Investigations” (PDF)
- Read the January 2020 ForwardHealth Update, “New Policy Allowing Local Health Departments to Contract for Environmental Lead Investigation Services” (PDF)
- Read the December 2021 ForwardHealth Update, “Permanent Telehealth Coverage Policy and Billing Guidelines” (PDF)
FAQs (frequently asked questions)
Below are some FAQs about Medicaid reimbursement for lead-related services. We’ve divided them into categories by subject:
- General information
- Nursing education visits
- Environmental lead investigations
- Nursing and environmental information
Claims can be submitted two ways:
- Electronically, by using:
- The ForwardHealth Portal’s online claim submission software
- The Provider Electronic Solutions claims submission software
- The Division of Medicaid Services (DMS) offers electronic billing software at no cost to the provider. You can download it on the FowardHealth Portal. If you need help installing and using the software, call the Electronic Data Interchange Helpdesk at 866-416-4979.
- By mail or fax, by using the 1500 Health Insurance Claim Form. ForwardHealth doesn’t provide this form. You can get one from any federal forms supplier.
You can view the most recent reimbursement rates for services by using the max fee schedule on the ForwardHealth website.
There are several procedure codes that can be billed for each child:
Blood Lead Testing Codes
- Office/outpatient visit (established patient): 99211
- Specimen handling office-lab: 99000
- Capillary blood draw: 36416
- Blood lead analysis (assay of lead): 83655
- Nursing visit (must be completed by registered nurse): T1002
- Environmental investigation: T1029
Claims can be submitted within 365 days of the date the service was provided.
To bill Medicaid for a home visit or environmental investigation, the child must have one capillary or venous blood lead level greater than or equal to 5 µg/dL.
If you’ve used DHS-approved templates for the property investigation or clearance report you created as part of your lead investigation, that will work. Because the DHS-provided nursing case management form only includes the initial home visit date, we recommend documenting any subsequent education visits, as well.
No. Local health departments that are HealthCheck providers may submit certain claims to Medicaid because they are considered enrolled FFS (fee-for-service) Medicaid providers. A local health department must enroll as a HealthCheck screening provider to bill for lead investigations and education visits.
Local health departments can enroll as HealthCheck providers to do screens, case management, or both. Local health departments that are enrolled as HealthCheck screener or HealthCheck screener/case management providers can bill for lead investigations and nurse education visits.
The local health department becomes certified as a HealthCheck screener or HealthCheck screener/case management, which lets the health department bill for services performed by the department staff. To bill for an education visit, however, a registered nurse must perform it.
You can find information on ForwardHealth’s provider enrollment information page.
Yes. Medicaid will reimburse for the costs of individual services provided, including:
- Nurse education home visits.
- Initial lead investigations (i.e., lead risk assessments).
- Follow-up investigations (i.e., clearances).
You can then use your funds from the CLPPP consolidated contract for other lead-related activities covered under your contract with the Division of Public Health (DPH) and for costs not covered fully by the Medicaid reimbursement. You can’t use funds from the CLPPP consolidated contract for costs that can be reimbursed by Medicaid.
Nursing education visits
A billable unit is a single block of time up to 15 minutes. Up to four billable units (totaling up to one hour) may be billed per day, per provider, per child.
Home visits for education by a registered nurse are submitted for 15-minute increments. Up to four units (totaling up to one hour) can be submitted per day, per provider, per child.
No. You can only submit a claim for an in-home lead education visit if it’s performed by a registered nurse. The billing procedure code (T1002) is for registered nursing services.
Due to COVID-19, a temporary telehealth policy is in effect and a nurse education visit performed over the phone can be billed. Learn more in the December 2021 ForwardHealth Update, “Permanent Telehealth Coverage Policy and Billing Guidelines” (PDF).
Environmental lead investigations
The local health department that employs the certified lead risk assessor submits the claim for the services.
No. LeadCheck swabs can’t be used when conducting a lead risk assessment or clearance investigation. You can test paint using an X-ray fluorescence analyzer, or by taking paint chip samples. You can test dust by taking wipe samples.
Yes. Submit a claim for the cost of the time spent doing the visual assessment, even though you couldn’t collect dust wipe samples.
No. You must collect dust wipe samples when conducting clearance after interior work.
Yes. Medicaid lets local health departments bill for lead investigations performed by private lead risk assessors and use the funds to pay them.
Submit a claim for the actual amount it cost you to provide the service, even though you’ll only be reimbursed for the maximum fee allowed for that service. Including it will give Medicaid an accurate look at how much it costs to perform the work.
You can bill for investigations of two homes when the child regularly spends time at each as part of the parents’ shared custody arrangement. You can’t bill for other homes for the child, such as the babysitter’s or grandparent’s home, because they’re not considered the child’s residence.
Yes. The local health department can bill for the home’s lead investigation, even if the child no longer lives there.
Yes. You can bill for one property investigation every 12 months. You can bill for the lead investigation of the home where the child tested high, even if the child no longer lives there.
No. There isn’t a required time period between when the child’s blood lead level is drawn and when the environmental investigation is conducted.
No. The home must be associated with a blood lead level of 5 µg/dL or more while the child is living there for Medicaid to cover it.
Nursing and environmental information
Only a certified lead hazard investigator or certified lead risk assessor can perform a clearance investigation.
Yes. If the person is both a registered nurse and a certified lead hazard investigator or risk assessor, you can submit claims for both services performed on the same day.
You can only bill for the education home visit conducted by the registered nurse. The billing procedure code (T1002) is for registered nursing services. Services you can bill for an environmental health specialist are the initial environmental lead investigation (i.e., risk assessment) and the follow-up investigation (i.e., clearance).
You should include the nursing assessment when billing for the education visit. It’s separate from billing for the lead investigation. If a nurse conducts both the education visit and the lead investigation, you should bill the services separately.
In general, federal grant programs don’t cover things that can be covered by other federal programs. With the consolidated contract, the funds should only be used to pay for services that aren’t covered by a third party, such as Medicaid. Always check a grant program’s specific requirements or restrictions.
No. Until the Medicaid reimbursement policy is changed, you can only bill for a child who has a blood lead level of 5 µg/dL.