Question Medicaid 14 visits

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Hi everyone!!

I just got a question from a doctor who asks if we can bill a visit without it "counting" toward the 14 allowed annual visits for medicaid. The patient will be coming in often for ADHD check ups and he would like to save the 14 visits for times when the patient is actually sick. He thinks there is a modifier to add to a regular e&m office visit (99213)

has anyone heard of anything like this before?
 

sls314

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Hi everyone!!

I just got a question from a doctor who asks if we can bill a visit without it "counting" toward the 14 allowed annual visits for medicaid. The patient will be coming in often for ADHD check ups and he would like to save the 14 visits for times when the patient is actually sick. He thinks there is a modifier to add to a regular e&m office visit (99213)

has anyone heard of anything like this before?


What state is this for? Medicaid coverage, coding, and billing is very state specific.

I've never heard of a state only allowing 14 doctor's visits a year! That's really odd - makes me wonder how they arrived at 14 being the acceptable amount.

My state has no limit - it's just based on medical necessity.
 

sls314

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Sorry, my mind is still blown by a 14 visit limit.

So if a person has a chronic illness that requires visits with different specialties, they just...stop going to the doctor? Or pick one illness to treat and let the other one go by the wayside? Yikes.

I work in Oncology, and I'm trying to figure out how our patients would even survive. Just to get a diagnosis, they're probably using several visits with their primary and/or a specialist. Then if they're undergoing treatment, they'll have visits with the oncologist too. (Possibly 2 oncologists - medical and radiation - depending on the treatment plan.)
 
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What state is this for? Medicaid coverage, coding, and billing is very state specific.

I've never heard of a state only allowing 14 doctor's visits a year! That's really odd - makes me wonder how they arrived at 14 being the acceptable amount.

My state has no limit - it's just based on medical necessity.
Did some research and found that Alabama does have a visit limitation, there are a ton of "stipulations" too. But...my mind is equally blown !
 

csperoni

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NY also has a limit (don't recall offhand what it is), but you can submit a "Threshold Override Application" and request additional visits for the year. I don't recall ever having the request for additional visits denied. Perhaps your state has a similar form or process to appeal for additional visits.
 
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