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Unlisted E/M codes and Medicaid

  1. #1
    Default Unlisted E/M codes and Medicaid
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    Ok, this doesn't happen often but it does happen. Medicare has advised us when an E/M service is provided but the documentation does not support the code you use an unlisted code.

    So for an admit, you only have an EPF history, the lowest level 99221 requires detailed. Per Medicare we would use 99499 and send notes. Ok, this works they pay.

    Medicaid, is turning into a different story. I have spent an hour on the phone today and I am currenlty waiting for a call back.

    Medicaid doesn't pay for unlisted codes without an auth, or so they told me today. They have batted me back and forth between 3 different departments so far. So my question to them is would the appropriate way to handle this be with the unlisted or would we use the defined code with a 52 modifier.

    Does anyone have any type of guidance from medicaid on this situation?


    Laura, CPC, CEMC

  2. Default
    Hi Laura,

    Medicaid never pays for unlisted E/M code or with modifier 52. We have been billing subsequent service based on PE and MDM and we were also told that we can follow it by Medicaid.
    Jagadish, CCS-P, CPC

  3. #3
    North Carolina
    In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499. A description of the service provided must accompany the claim. The carrier has the discretion to value the service when the service does not meet the full terms of a CPT code description (e.g., only a history is performed). The carrier also determines the payment based on the applicable percentage of the physician fee schedule depending on whether the claim is paid at the physician rate or the non-physician practitioner rate. CPT modifier -52 (reduced services) must not be used with an evaluation and management service. Medicare does not recognize modifier -52 for this purpose.

    Our Medicaid carrier has a policy in place for this type of situation...Unlisted procedure codes: "The claim must be submitted on paper and include a special report and operative notes or medical records. Medicaid cannot evaluate and reimburse the service or procedure without adequate documentation." Our Medicaid carrier doesn't recognize modifier 52, either.

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