Wiki Medicaid & Unspecified CPT Codes

[SSThomas03]

Does Medicaid reimburse unspecified CPT codes? If they do not, are we allowed to submit a comparison code with an appropriate modifier?

The reason I ask is our facility billed CPT code 46999 with the description, "hemorrhoidectomy, external, single column/group" per documentation and coding guidelines. Unfortunately, we received a denial, code 189, that stated, "Incorrect procedure code billed for procedure/service". Our AR representative called Medicaid and was informed code 46999 was not billable per the provider's credentials, so we are unsure if it is a provider or CPT code billing issue.

 

[eurodurk]

The office I bill out of had a similar situation a few months ago, so I may be able to provide some insight...

I know Medicaid plans differ state-by-state, but the state I bill out of (Michigan), does not accept unspecified codes, and we must write off any codes that are categorized as unspecified, unless we have notified the patient before services were rendered that they might be responsible for payment. (Michigan Medicaid laws typically follow federal Medicare laws, which makes it a bit easier to remember.) We were able to find this information in the Michigan Medicaid provider manual, so your state might have the information easily available in a similar document.
I would encourage you to check and see if your state follows similar guidelines.

There are also some codes that will be rejected by our state's Medicaid as being 'unpayable' (for reasons that remain unknown to me), so you might also want to double check and see that it is a code that is covered by your state's Medicaid.
If all else fails, it could just be a code that will only be paid to certain provider types. For example, my office sees this often with Blue Cross plans, where they pay for a code when performed by a primary doctor, but will not pay for the same code when performed by a podiatrist. I wouldn't expect this to be the case, since it is a Medicaid patient, but it's always a possibility.

Even though I don't have an exact answer for you, I hope I was able to help, at least a little!