Wiki CPT code not in Medicaid Fee Schedule

[yahairag2@aol.com]

Hi all,

My EP physician coded a 33274 for a single chamber leadless permanent pacemaker. NY Medicaid does not have that CPT code in their fee schedule. I have looked for any other in the CPT book and cannot find one. Has anyone else bumped into the same issue? If so, what did you do? Or, can anyone advise how I can code this.

Thank you,
Yahaira from NY

 

[sls314]

Hi all,

My EP physician coded a 33274 for a single chamber leadless permanent pacemaker. NY Medicaid does not have that CPT code in their fee schedule. I have looked for any other in the CPT book and cannot find one. Has anyone else bumped into the same issue? If so, what did you do? Or, can anyone advise how I can code this.

Thank you,
Yahaira from NY

I would try looking on the NY Medicaid website to see how they reimburse codes that aren't on the fee schedule.

I've worked with Medicaid reimbursement in multiple states, though I haven't worked with New York. Other states would typically have a rule that valid codes not listed on the fee schedule would be reimbursed at a percentage (often the cost to charge ratio).

New York Medicaid should have the payment methodology listed somewhere for that circumstance.

 

[CFE4130]

I'm dealing with the same thing. I'm not sure if this is the same in other states, but Louisiana uses Managed Care Organizations (MCO) which are the middle men between the provider and Medicaid agency. Acne surgery 10040 is not listed in the fee schedule. I was just informed that the MCOs can cover additional codes as long as the y represent the covered services under the contract. So I think now we have to check with each MCO to see if it is a covered in the contract. I hope this helps.

 

[yahairag2@aol.com]

I would try looking on the NY Medicaid website to see how they reimburse codes that aren't on the fee schedule.

I've worked with Medicaid reimbursement in multiple states, though I haven't worked with New York. Other states would typically have a rule that valid codes not listed on the fee schedule would be reimbursed at a percentage (often the cost to charge ratio).

New York Medicaid should have the payment methodology listed somewhere for that circumstance.

Ok, thank you.

 

[yahairag2@aol.com]

I'm dealing with the same thing. I'm not sure if this is the same in other states, but Louisiana uses Managed Care Organizations (MCO) which are the middle men between the provider and Medicaid agency. Acne surgery 10040 is not listed in the fee schedule. I was just informed that the MCOs can cover additional codes as long as the y represent the covered services under the contract. So I think now we have to check with each MCO to see if it is a covered in the contract. I hope this helps.

I will look into that, Thanks.

 

[losborn]

I work with Medcaid extensively and have been able to speak with them on the telephone. On more than one occaidsion, and for more than one code set (CPC and HCPCS) Medicaid assured me that if it is not in the Fee Schedule, it is not a covered service.