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Medicaid denials for ER code even after billing with 25 modifier

  1. #1
    Default Medicaid denials for ER code even after billing with 25 modifier
    Exam Training Packages
    Good Morning!

    Medicaid is denying ER code when billed with surgery. I have appended 25 modifier to ER.But still the ER is denied as inclusive to the procedure. We tried tagging different primary diagnosis with ER and surgery and denial still continues. This is for the state Oklahoma

    Is there a different way of billing the above scenario to get the payment for ER as well?


    Thank you
    Thank you,
    Meera Mohanakrishnan, MSc, CPC, COC, CPC-P, CRC (Risk Adjustment), CCS (AHIMA) ,CPC- I (AAPC Approved Instructor) , Certified ICD 10 Consultant, PAHM |
    Director – Medical Coding Operations and Training

  2. Default
    What kind of procedures are being done?
    Dee
    CPC, CPCO, CPMA, CPCD

  3. #3
    Location
    Las Vegas
    Posts
    32
    Default
    So many state medicaid programs have their own "system of coding". In Nevada, they don't like LT or RT or "50" so I know the challenge you are facing. Have you tried billing it with a modifier 57 - Decision for surgery. If they still deny it, I would see if you could find a "live body" to talk with or who you write an appeal to. Did the ER physician perform the surgery or did a different surgeon do the procedure? Just some ideas, as I said even thought Medicaid programs are "federally funded", many of them have their own concept of coding and with the one I dealt with in Nevada, God forbid you dare challenge them even with CPT, ICD-9 and HCPCS code books and federal regulations in hand. Good luck!!!

  4. #4
    Default
    Quote Originally Posted by meeramohanakrishnan View Post
    Good Morning!

    Medicaid is denying ER code when billed with surgery. I have appended 25 modifier to ER.But still the ER is denied as inclusive to the procedure. We tried tagging different primary diagnosis with ER and surgery and denial still continues. This is for the state Oklahoma

    Is there a different way of billing the above scenario to get the payment for ER as well?


    Thank you
    Try modifier 57 (decision for surgery), if your documentation supports it. Appeal it with records if it denies.

  5. #5
    Location
    Northeast Kansas AAPC
    Posts
    271
    Default
    In Kansas the straight Medicaid program will not allow any E/M with a procedure on the same date of surgery. There are some other "state" programs that do allow and the patients switch mid month etc between programs so we just bill all of them and if they do not pay we just write them off. Doesn't make sense but that's what we have to do.

  6. #6
    Default
    ER provider performs a minor surgery like suture removal, debridement etc.
    We append 25 modifier to ER code.But the Medicaid insurance denies ER code as inclusive in the minor surgery procedure
    Thank you,
    Meera Mohanakrishnan, MSc, CPC, COC, CPC-P, CRC (Risk Adjustment), CCS (AHIMA) ,CPC- I (AAPC Approved Instructor) , Certified ICD 10 Consultant, PAHM |
    Director – Medical Coding Operations and Training

  7. #7
    Default
    We have tried even appealing with medical record.Still the ER is denied as inclusive to minor surgery procedure
    Thank you,
    Meera Mohanakrishnan, MSc, CPC, COC, CPC-P, CRC (Risk Adjustment), CCS (AHIMA) ,CPC- I (AAPC Approved Instructor) , Certified ICD 10 Consultant, PAHM |
    Director – Medical Coding Operations and Training

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