02/16/2022

Medicare to Medicaid Conversion

Question is about medicare to medicaid conversion. What is the appropiate cpt conversion on a routine foot care 11055 to medicaid as well as 11719 on a covered service with initial cpt code 11720? What has happened in a unmet deductible, medicaid would pay only for intial cpt but not the second one? Thank you for your help.

There is no conversion of CPT codes when a claim is autocrossed from Medicare to Medicaid. Whatever procedures are billed on the claim to the primary insurance must be billed to the secondary insurance if there is any outstanding patient responsibility. With Medicaid, even if Medicare covers the procedure and applies it to the patient’s deductible, if the CPT code is not on the Medicaid fee schedule, it will not be reimbursed and the patient cannot be balance billed for the deductible. Medicaid will cover nail debridements (whether billed under CPT 11720 or 11721). Medicaid will not cover the removal of corns & calluses (CPT codes 11055-11057) or nail trimmings (under 11719 or G0127). Balance billing a patient for a deductible when they are a Medicare QMB may have negative consequences such as sanctions that could affect participation in the Medicare and Medicaid programs.