Know Your Carriers’ Nuances When Billing for Medicaid

When billing Medicaid, know how your carrier interprets the official code sets. Many times they want you to use HCPCS Level II codes in place of CPT® or special modifiers for payment indicators. This requires additional research to determine which code the carrier wants. By defaulting to an evaluation and management (E/M) code, you do your practice a financial disservice.

Think about this scenario: A child comes in for special screening before going on vacation with her mother. Past allegations of abuse exist. The physician must examine the child and fill out an official form – sometimes as long as eight pages – prior to the child being turned over to her mother. Many practices try to report this with an E/M service, and this may or may not get paid with a preventive diagnosis code. Whether it is paid is irrelevant if the service does not meet the definition of an E/M service. You are left wondering how to get your physician paid for all the work he or she did.

CPB : Online Medical Billing Course

The bottom line is this: Reporting an E/M code may only get you about $30 in payment but by properly billing with the appropriate HCPCS Level II code, you are able to receive about $60. Payments and policies vary by state. Be sure to do your research; contact your payers’ provider representatives, and make sure your physician receives payments to which he or she is entitled.


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