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Thread: Medicaid/Medicare Billing

  1. #1

    Default Medicaid/Medicare Billing

    AAPC: Back to School
    I hope someone can help me with this. In our hospital we bill the allowable 99215 for each OB visit but does this matter if the amount totals of the total pregnancy package is more than what our global package is for a commerical insurance? Please help.

    Thank you

  2. #2

    Smile Here's a Thought ...


    If I am understanding your question correctly ...

    "Yes" ... bill for the office visit, but if you want to get paid for the Office Visit ... you will need to show 2 diagnoses on the UB04 form. Have the doctor ok this ... and he will need to do his tasks for the office visit (Time, MDM, History) ... but link the office visit to a more generalized DX, and link the pregnancy to something more specific. This will ensure both the Office Visit and pregnancy get paid.

    I think that answers your question ...

  3. #3
    Join Date
    Apr 2007
    Columbia, MO


    I do not understand what the original poster is asking, but I also do not understand the above response. If this is a pregnancy visit then you cannot make it about something else, I do not understand what you mean by "link the ov to a generalized dx and link the pregnancy to something more specific. " If this is a pregnancy encounter then it must be coded that way. If the patient has a pregnancy complication then it is coded that way if the patient has some other condition, unless documented as not causing a problem with the pregnancy or management therof we must use a pregnancy code first listed such as 648.xx. I just would like to get clarification from both posts.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4

    Default Medicaid/Medicare Billing

    I am so sorry obviously I did a very poor job in explaining what I was asking.

    Let me try again... Of the two choices of billing either the global or individual visits for an OB, we choose to bill individiual visits which in Maine is 99215 for each OB visit. My question is: If the 13 visits of 99215 plus the delivery fee equal "more" than what we are billing for a global for a "commercial" carrier does this matter? Is there a rule stating Medicare/Medicaid cannot be billed more than a commercial carrier for services. I hope I did a better job this time.

    Any and all help is appreciated!

    Thank you


  5. #5

    Default Mainecare Maternity Billing

    Hi, Bonnie:

    You are billing based on the Medicaid regulations. The Maine regulations do state that the provider has a choice. They make it very clear that it is not based on what is least expensive for MaineCare or any other criteria other than provider choice, so you are within your rights to bill based on your preference. The only stipulation is that a global cannot be billed unless the patient had Mainecare the whole time and a certain number of visits were completed during the pregnancy.

    It also says that even if you bill globally, any visits for routine maternity care after the 11th can be billed separately.

    It also states that complications of pregnancy or treatment outside of the pregnancy can be billed separately, so the second answer, which I believe was trying to explain how to bill a service provided during pregnancy that was not related to the pregnancy is also correct. But since you are billing each visit, you would clearly just bill it based on the patient's medical treatment/diagnosis of the day.

    There are rules in the Federal Register that prohibit "billing for cash", but the practice you have here is clearly not a violation of any fradulent billing scenarios listed there.

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