1. A

    UT Medicaid Urine Drug Testing Carve-out

    I know this is a rather specific question so even if you have any input that would be fantastic. I've been going back and forth for the last 5-6 years with MCOs in Utah about the substance use disorder (SUD) carve out for UDT. The only place the carve-out is mentioned is in a MIB from April 2018...
  2. B

    Question Is there a non-3M way to group APR-DRGs?

    I need to assign APR-DRGs so that I can calculate state Medicaid reimbursement for some hypothetical patient cases, but I don't have access to the 3M encoder (which costs tens of thousands of dollars). Is there another way to accomplish this?
  3. A

    Question Patient With Medicaid in 2 States - Who would you bill?

    I have occasionally come across patients who, somehow & some way, have active Medicaid in two states. For example, they have active Medicaid in Arizona while being active with Medi-Cal at the same time. I've also seen one state have a COB with another state (ex. Nevada Medicaid shows that...
  4. K

    Wiki Billing J0129 to Medicaid

    Hi everyone, I work in a Rheumatology office where we perform several injections and infusions weekly. As of recent, Medicaid has denied J0129 Orencia as a non covered charge due to the fact it was recently added to the SAD list. Any advice on how to bill this would be greatly appreciated, as...
  5. R

    Question Encounter Data Validation Medical Record Reviews?

    Hello, I hope I can explain this correctly. I have a question regarding encounter data validation - medical record reviews for an inpatient scenario. A patient was admitted inpatient for psychiatric issues. They were inpatient for a week from beginning date of service to end date of...
  6. T

    Wiki 99406 denial

    I am getting a denial from Medicaid as secondary to Medicare. Primary Cpt Code 99309 (NURSING FAC SUBSE DETAILED) was paid by Medicaid. Medicaid is denying Second cpt code 99406 for POS. POS is 31 for this provider for both codes. Is this POS for this code not payable per Medicaid guidelines for...
  7. B

    Hospice Modifiers

    Hello! I am coding for a Hospice group and all of our claims for a patient have been denied from Amerigroup Medicaid for modifier TG. I have looked at the website they provided and I cannot find a modifier for High/complex level of care that is Medicaid approved. Anyone have any ideas for what...
  8. D

    Referral Carolina Access - Medicaid NC

    I know standard Medicaid does not require a referral and I understand that Carolina Access does for a specialist. My question is does the referral have to have an authorization number on it? I thought it did and when I called the PCP and asked for one I could feel them stare at me through the...
  9. J


    How do you guys handle COB issue with Medicaid patients? We tried to contact patient, but patient does not return any response. Insurance is stating we can't bill Medicaid patients for COB issue.
  10. S

    Wiki Medicaid Billing Groups?

    I was hoping that someone would know online billing groups or forums I can join for Medicaid to get help and tips for billing and coding.
  11. E

    Wiki 99358

    We are billing 99358 to BCBS and Aetna medicare advantage plans and medicaid. They are denying this code. Is anyone else having this issue? Is there something we can be doing to get this paid? We are billing for nursing facilities. The providers review patient records before being seen in facility.
  12. E

    Denied Medicaid Claim

    First off, I absolutely hate Medicaid with a passion (lol) I'm located in Michigan and I received a denied claim Adjustment Reason Code 16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other...
  13. A

    2021 E/M Changes - Will Medicaid Follow The New Guidelines?

    Hello! Has anyone heard from their Medicaid carrier if they are going to follow the 2021 E/M guidelines? I have checked on the website and on my local Medicaid DHS website and see nothing about this in their bulletins or FAQs. Thank you!
  14. K

    Contracted with Medicare/other insurances but not Medicaid

    If a practice is contracted with Medicare and other commercial insurances, but not medicaid.. Does the patient legally have to pay their primary insurance co-pay? For example, the patient's primary insurance is United, but their secondary is some type of medicaid plan. If United decides there...
  15. R

    Question Utah Medicaid Billing for IOP services (HELP!)

    We are new to Utah Medicaid, and unfortunately they do not accept H0015 for IOP for SUD. I am at a loss for what I am supposed to bill. Does anyone have any guidance with Utah Medicaid billing??
  16. B

    Question E&M coverage for private insurance vs Medicaid

    Hello. I live in AZ and we have state Medicaid (AHCCCS). I have a question regarding dual (or more) insurances and billing E&M codes. I have patients that have private insurance (i.e. BCBS/UHC/Cigna) as primary and Medicaid as secondary. Do I use the E&M code (i.e. G0108) that I know the...
  17. D

    Wiki Nevada Medicaid Denials

    I am new to medical billing. I work in a public health clinic and we bill for immunizations primarily. The claims were first denied because our provider wasn't linked to our Medicaid group. After that was fixed I did a little research and I now know that Medicaid will not cover the vaccines...
  18. B

    Question Nuchal cord in delivery

    When a delivery summary states "nuchal cord x1, loose, slipped over head" does that require the O69.81X0 Labor and delivery complicated by cord around neck, without compression, not applicable or unspecified? I'm in Vermont and Medicaid is denying claims stating the O69 code cannot be primary...
  19. J

    Medicare COB Question for IP Stay

    When a member becomes eligible for Medicare Part A in the middle of their Inpatient stay, how is the biller to submit a claim? The patient had Medicaid State SSI as coverage upon admission which fell to secondary payor once the patient was entitled to Medicare Part A. Is SSI responsible for the...
  20. L

    Billing Medicaid patients for unpaid covered services?

    Hello, A private company that offers plans for patients that are found eligible for Masshealth (Medicaid) has been inconsistent with payment of services. We have quite a few patients that have claims that should be covered and the insurance company acknowledges their error in denying their...
  21. A


    my group provides mental behavioral health services, psychology/psychiatry, in nursing facilities that we're contracted with in 5 states. Medicaid KEEPS denying our 99484, 99358, and 99359 claims. Is there a specific way aside from the requirements we're all aware about of a claim form that may...
  22. J

    Question Antepartum, Delivery, and Postpartum Care Medicaid Billing

    Hello, I work for a large Ob-Gyn practice and we were looking to see how other large practices handle billing Medicaid antepartum, delivery, and postpartum care. For example: We have a patient who we provided antepartum care by various providers of the same group, delivery, and postpartum...
  23. E

    Wiki CMS/Medicaid Pay To Provider Question

    Hello, We have been having problems with our billing system where MEDICAID claims are paying to the member's PCP, not the rendering provider. Before going to the manufacturer to get changes to our billing system, is this a Medicaid or CMS rule/regulation? I have searched their website through...
  24. K

    Medicaid overdue claims

    We received denial from Medicaid coverage guidelines were exceeded. Rep suggest to fill application on web-portal. I am a bit confused. Any suggestions
  25. G

    Denials from medicaid

    Hello, I have run into an issue with Medicaid stating that 1) L21.0 has an age limit. This I don't understand because this is a code for Dandruff and anyone can get dandruff at any age? However there are no other appropriate codes to assign to this patient from the medical record. 2)...
  26. J

    Wiki Outpatient hospital billing under new EAPG payment system

    We bill as an outpatient dept of a local hospital (not an ASC) How are bilateral procedures supposed to be billed? We always billed Medicaid and Medicaid Replacement plans with 2 lines, the first w/ RT modifier and the second w/ LT modifier. They would not accept modifier 50. Now they are...
  27. J

    Eligibility Verification

    Does anyone have any good advice on the best way to set up auto-eligibility verification? Any examples of software applications that are really efficient? We are wanting to have an automated process that will generate a report for our persons served receiving Medicaid coverage. We are located...
  28. A

    Wiki Encountering multiple services for open Medicaid client

    I work for a Medicaid managed care organization and am wondering about the appropriateness around encountering/billing multiple services for a client when the client is open to services in multiple facilities. For example, if a client is in a psychiatric residential treatment facility, can a...
  29. Rebecca Pate

    Vitamin D Deficiency and Medicaid

    Since Medicaid does not accept any unspecified codes, and the only code available for Vitamin D Deficiency is unspecified (E55.9), what is everyone doing? Can we not ever use this for Medicaid? Any help would be appreciated. :confused::cool:
  30. S

    Billing Medicaid first for medical or billing Medicaid Amerihealth first

    I'm new to billing and coding. When patient has both, which one do we bill first for a medical Dx, medicaid Avesis or Medicaid AmeriHealth? :p
  31. J

    PA Medicaid Requirements

    I bill and code for a pediatric practice in Pennsylvania. Recently Medicaid updated their EPSDT schedule and they are requiring we use 96160 for administering a depression screening to a caregiver. Obviously it should be 96161. I am looking to see if anyone has had experience with getting...
  32. D

    new to OB coding - some basic questions re: FL Medicaid

    Our practice has midwives and an ARNP only. No physicians in this specialty. I think i'm doing fine on the deliveries, but i'm finding it difficult to locate info on how to bill for office services. Medicaid has limited information in their manual. Does anyone know of a more instructive article...
  33. A

    Billing for services before MH assessment?

    I work for a Medicaid organization and am wondering if it is appropriate to bill for services before an assessment is done. For example... 1. Case Manager works on paperwork for a member for 30 minutes for housing prior to taking them face to face to Housing Authority for 1 hour- Can they bill...
  34. C

    Post Op Cataract Visits

    We have recently discovered that because we are an Optometry office, Medicaid will not reimburse us anything for the patient's post op cataract visit. Since we cannot bill 66984 to Medicaid, does anyone know if we can still bill a 99213 OV code with the cataract dx or is this considered fraud...
  35. A

    Wiki No Show Fee for Medicaid?

    Hello! Does anyone know where I can find information as to whether an office can charge a Medicaid patient a no show fee or not? I am finding several different answers. I work in North Carolina. Thank You!
  36. S

    Charging Medicaid Pts for Chiro visits exceeding the coverage limit?

    In California, there is a twice monthly limit on covered benefits for Chiro. If a Medi-Cal (Medicaid) Pt wants additional visits of the sort, are we allowed to chage them? I know that we can charge for uncovered benefits and we frequently do, in dental, particularly. But these are covered...
  37. C

    Z36 - Medicaid

    In our office we will do a dating ultrasound in which we use Z36 and Z3A. Patients are also offered genetic screening, some will have a specific diagnosis that we can use but for other simply wanting it for peace of mind we have been using the code Z36 also. Up until recently we haven't had a...
  38. D

    Medicare/Medicaid secondary: HCPCS services non covered by Medicare paid by Medicaid

    Hi, I work for a community mental health center and most of our services that we render are HCPCS and covered by Medicaid. My question is: Since the services are not covered by Medicare do we bill Medicaid directly or do we still need to bill Medicare as primary? I have asked this question...
  39. A

    Billing Medicaid for Postoperative Eyeglasses for Cataract Surgery

    I work in an ophthalmology office and am constantly billing post operative eyeglasses for cataract surgeries to DME and have had no problem getting them paid. (We use CPT codes V2303, V2305, etc. and ICD-10 code Z96.1). I have recently tried billing Medicaid for a pair of post operative...
  40. A

    Billing Post Op Eyeglasses after Cataract Surgery to Medicaid

    I work in an ophthalmology office and am constantly billing post operative eyeglasses for cataract surgeries to DME and have had no problem getting them paid. (We use CPT codes V2303, V2305, etc. and ICD-10 code Z96.1). I have recently tried billing Medicaid for a pair of post operative...
  41. K

    Residential Treatment and DCS Contracts

    I work for a mental health facility that has a contract with DCS as a residential treatment facility. We have a building for Level 2 and Level 3 patients. If they are in the state's custody, Level 3 clients' services are only billed to DCS. If they have private insurance, Level 3 client's...
  42. M

    Observation Codes - Medicaid

    Hello, I am hoping I can get some feedback regarding the coding and billing of Hospital Observation codes for Medicaid patients. According to the HFS Handbook for Practitioners (Observation Section A-220.4) - - "Payment will not be allowed for...
  43. B

    Wiki Need modifier

    Hi Here I am getting wrestle to fix the below mentioned claims... Now I am frequently getting denials with the CPT H0023 as “missing modifier” from Medicaid insurance. I am new to see this HCPCS code, please give me your suggestion on this
  44. J

    Medicaid not covering full $166 medicare deductible.-Is anyone else

    Is anyone else having issues billing medicaid for the full $166 deductible? New York medicaid is telling me they wont pay for deductible amounts over $150. I'm telling them Medicare's new deductible is $166, they don't know what I'm talking about and insisted the charges are invalid. It's like...
  45. J

    Wiki Medicaid not covering full $166 medicare deductible.

    Is anyone else having issues billing medicaid for the full $166 deductible? New York medicaid is telling me they wont pay for deductible amounts over $150. I'm telling them Medicare's new deductible is $166, they don't know what I'm talking about and insisted the charges are invalid. It's...
  46. D

    Insurance Verification/ Medicare & Medicaid

    Part of my new position aside from coding is demo and insurance verification. For verifying Medicare and Medicaid aside from replacement policies. Is there a main website for Medicare and Medicaid to verify coverage with out having to get into separate state sites? If anyone has any info I would...
  47. N

    IL medicare xover claims

    Recently our office has experienced claims NOT crossing over from IL Medicare to IL Medicaid. Has anybody else been seeing this happening?
  48. P

    Wiki Medicaid FFS - Nevada - 51/59 modifiers

    I bill for an OB and am trying to bill 58552 with 57282. These two codes do allow a modifier. Medicaid keeps denying for incorrect modifier. We tried 51 and 59 on the 57282. Any thoughts or is anyone else having this issue with NV Medicaid?
  49. C

    Wiki Is the Q0 modifier required for OP Medicaid Patient getting an AICD?

    I am curious if the Q0(zero) modifier is required to be added to CPT 33249 for patient undergoing a OP procedure for implantation of an Automatic Implantable Cardiac Defibrillator primary prevention. I know thi sis required for Medicare. I am unsure is this applies to Medicaid. Any help would...
  50. L

    NC Medicaid help please?

    We have an ENT dr that does procedures in our facility (ASC), we are having an issue when he does a T&A (42820) or Tympanostomy (69436) along with any 30802,30930, or 30140... We get paid by commercial carriers however NC Medicaid doesnt pay but for the primary procedure. I am thinking this is...