Medicaid-Patient's primary

tmoss1

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Patient's primary insurance paid for 99242 consultation except $25 copay. Patient's secondary ins Medicaid denied cpt 99242 as non covered by plan. Can we bill the patient for the $25 or do we have to adjust it off?
 

thomas7331

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Most Medicaid plans prohibit billing an eligible patient for balances other than any cost share that is indicated on the Medicaid EOB. Best to check with your state's Medicaid provider guidelines which usually spell out pretty clearly in their provider manuals under what circumstances you are allow to collect from the patient.
 

CodingKing

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This situation always stumps me. Primary carrier wants you to code one way and secondary carrier wants you to code a different way. How do you go about getting reimbursed by the secondary. The issue here is likely the Primary allows consult codes and Medicaid, which typically does what Medicare, no longer accepts the consult code.

Are you able to bill a regular E&M to Medicaid? Do you have to do a correction with the Primary as a regular E&M and then rebill Medicaid? Although in this situation i'm thinking since the RVU on consults is higher, that writing off the remainder is probably a better idea. I assume the denial is sufficient documentation so no one can accuse you of illegally waiving copays?
 

AnnaE

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Medicaid

Patient's primary insurance paid for 99242 consultation except $25 copay. Patient's secondary ins Medicaid denied cpt 99242 as non covered by plan. Can we bill the patient for the $25 or do we have to adjust it off?
It is a w/off.
 

hopepg

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Another provider I worked for in the past had this issue when Medicare & Medicaid plans began not covering consult codes. When we ran into this scenario (primary allows consult codes / secondary/tertiary does not allow consult codes) The provider would bill a regular E/M code on patients in this scenario. This decision was made after contract rates were evaluated for payers in question for the various consult codes versus E/M codes.
This is no a recommendation of what you should do...just sharing what a provider did that I used to work :)
 

TishCpc

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Patient's primary insurance paid for 99242 consultation except $25 copay. Patient's secondary ins Medicaid denied cpt 99242 as non covered by plan. Can we bill the patient for the $25 or do we have to adjust it off?
You can bill his copay because it is his secondary, I can tell you now the most they will pay is between $9.80 and 12.44. However I would drop the claim to paper and send the primary eob showing the patient responsibility.
 

TishCpc

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Modifier U2

Can someone explain the purpose of the modifier U2 on cpt 59514. When I look it up it only says Medicaid level 2, I want to understand so I will know to code with them or not.
 

CodingKing

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Another provider I worked for in the past had this issue when Medicare & Medicaid plans began not covering consult codes. When we ran into this scenario (primary allows consult codes / secondary/tertiary does not allow consult codes) The provider would bill a regular E/M code on patients in this scenario. This decision was made after contract rates were evaluated for payers in question for the various consult codes versus E/M codes.
This is no a recommendation of what you should do...just sharing what a provider did that I used to work :)
I'm thinking its best to use regular E&M codes especially if Medicare or Medicaid is one of the patients coverages (its also the safest as pretty much every payer accepts 99201-99215). I'm not surprised using regular E&M vs Consult doesn't have as much effect on the rate. Once Medicare stopped reimbursing Consultation codes they also raised the RVU on regular E&M to account for some of the loss.

You can bill his copay because it is his secondary, I can tell you now the most they will pay is between $9.80 and 12.44. However I would drop the claim to paper and send the primary eob showing the patient responsibility.
Are you sure medicaid even pays? The rate is so low usually the primary payer has paid more than medicaid would owe, causing the remainder to be a write off.
 
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