04/08/2019

Denials from Medicaid-Secondary to Medicare

I have had an issue with Medicaid when it is secondary to Medicare. As a specific example, I billed: 99212-25 linked to B35.3 11056 Q8 linked to I73.89 11721 Q8-59 linked to B35.1 & I73.89 All 3 codes were approved by Medicare and the entire amount went to the patients deductible. Medicaid paid the 99212 but denied 11056 and 11721. Reason for denial was CO-97. I called Medicaid and was told this denial is correct and I have no right to appeal. They will not pay office visit and procedure on the same day due to a policy change. Also, when multiple procedures are billed on the same visit, (with no e/m) they will only pay for one procedure. That procedure being “whichever line item is received first”. Is Medicaid correct in denying these claims and, if not, how can I appeal?

The information from customer service at Medicaid is giving correct information- NY Medicaid will pay one of the following:

• An E&M code for patient encounter, or
• The surgical procedure with the highest reimbursement (subsequent service lines will not be paid due to a benefit maximum, where payment will be inclusive to the payment for the complex procedure)

The most recent documentation regarding payment guidelines from Medicaid are not currently available on the eMedNY website. However, given the low reimbursement and complex payment rules from Medicaid, this would be an appropriate response from the payer in covering the Medicare deductible.