09/30/2020

Billing Medicaid (Secondary) for 99203 and 11042

I have a Medicare/Medicaid patient who was a new patient and had ulcer debridement. CPT 99203-25 CPT 11042 Medicare paid both codes as primary but Medicaid paid their portion on 11042 but denied the payment as supplemental on the 99203. When we called Medicaid, they said you cannot bill 99203 and 11042 on the same day. Is this correct?

The partial reimbursement from Medicaid is appropriate- if Medicaid covers any services as secondary, they will cover the highest paying procedure of all services billed, under the condition that the Medicare reimbursement is below the Medicaid reimbursement for the service. Based on the description below, the ulcer debridement is reimbursed at a higher rate than the new patient office visit, which justifies why Medicaid covered that charge as secondary. The deductible and/or co-insurance would be covered up to the secondary’s allowed amount, where the balance would be a write off. Since QMB patients cannot be billed, even though the office visit was allowed by Medicare, the patient responsibility would have to be adjusted since it is not covered due to the ulcer debridement being billed on the same encounter.