Wiki Medicaid consult and surgery same dos


Columbus, OH
Best answers
Hello coders, is there anyway to get paid for an e/m service on the same day as another procedure with Medicaid? Is this an overall Medicaid policy, or just Ohio Medicaid (where I am)? If the surgeon does a consult with a decision for surgery, is it still global to the surgery for Medicaid? I know modifiers can't be used on these charges. So I just wondered if anyone knows how to get the consult paid? Or is it just written off as global? And where is this documented so I can show it to my A/R manager? Thanks in advance for your help, Paula:confused:
if the consult turned into the decision for surgery - then why can't you use the modifier .57 on the E/M ?? what do you mean " I know modifiers can't be used on these charges."? why can't they?
Our Medicaid provider does not allow for payment for either a consult or E/M on the same DOS as a surgery. You can have one or the other, but not both.

I believe that this is VERY common for the majority of Medicaid carriers.
Wisconsin T-19 doesn't pay

Wisconsin T-19 Medicaid does not pay for an E/M service on the same date as procedure. We still code it with the 57 (or 25) modifier, but the charge will be adjusted off. We code the same regardless of payor. We just don't bill the same.

The reimbursement level from T-19 is not worth trying to appeal these.

F Tessa Bartels, CPC, CPC-E/M
I used to keep a list of all Medicaid that had a 25 or 57 modifier and pull those from the electronic batch and drop on paper with documentation attached. The denial is usually due to lack of documentation, try sending the documentation and it should get overturned. Another piece of advice.... contact your local Medicaid rep, ours has always helped when called upon.
It appears it is region specific. Our MCD carrier policy is as follows...

Select E/M services provided on the day of or the day prior to major procedures are considered included in the service for surgery and are not reimbursed separately. However, separate reimbursement can be made if modifier 57 is appended to the appropriate level of the E/M service to indicate that the initial decision to perform a major surgery was made during the visit on the day before or the day of the surgery.