Know Your Carriers' Nuances When Billing for Medicaid

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  • In Billing
  • February 23, 2011
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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.
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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