# Medicaid denial



## tmoss1 (Mar 3, 2016)

Can anyone help with this? We billed the patient's primary insurance for a consult cpt 99292. In each claim the primary insurance paid and applied a copay or applied the allowed amount to the patient's deductible. When we billed the patient's secondary insurance Medicaid they denied it as non covered. Can we bill the patient or do we have it write it off and receive nothing for the ones applied to the pt's deductible?


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## mhstrauss (Mar 3, 2016)

tmoss1 said:


> Can anyone help with this? We billed the patient's primary insurance for a consult cpt 99292. In each claim the primary insurance paid and applied a copay or applied the allowed amount to the patient's deductible. When we billed the patient's secondary insurance Medicaid they denied it as non covered. Can we bill the patient or do we have it write it off and receive nothing for the ones applied to the pt's deductible?



99292 isn't a consult code; it is the add-on code for additional critical care time. If that is a typo, and a different consult code was billed--Medicaid doesn't allow consults; the code will have to be crosswalked to the appropriate in/out patient E/M code.


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## tmoss1 (Mar 3, 2016)

Oops. Yes that was a typo. The consult code was 99242.  So the 99242 code will have to be changed to an appropriate E & M code? If yes, even if we billed this code to the primary code we can still crosswalk or change to appropriate E & M code for the secondary ins?


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## hopepg (Mar 4, 2016)

It is my understanding that you cannot bill the patient for that balance. 
This subject came up in another forum post not too long ago. This was/is my thoughts...
Another provider I worked for in the past had this issue when Medicare & Medicaid plans began not covering consult codes. When we ran into this scenario (primary allows consult codes / secondary/tertiary does not allow consult codes) The provider would bill a regular E/M code on patients in this scenario. This decision was made after contract rates were evaluated for payers in question for the various consult codes versus E/M codes. 
This is no a recommendation of what you should do...just sharing what a provider did that I used to work


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## mhstrauss (Mar 4, 2016)

tmoss1 said:


> Oops. Yes that was a typo. The consult code was 99242.  So the 99242 code will have to be changed to an appropriate E & M code? If yes, even if we billed this code to the primary code we can still crosswalk or change to appropriate E & M code for the secondary ins?



I agree with what hopepg posted as one of your options. Other things to consider:

After Medicare made the decision to stop accepting consults, they put out guidance that, when Medicare is secondary to a commercial payer (or any payer that still accepts consults), the provider can either 1. bill a consult code to the primary payer, then once claim is paid crosswalk the consult to an appropriate new/estab E/M code, and file that to Medicare secondary with the primary EOB. OR 2. not use the consult code at all, just file a new/estab E/M to both payers, which is easier in the long run, but you'll possibly be missing out on reimbursement from the primary payer. Depending on the primary payer's fee schedule, this may or may not be the right decision for your practice. There's a pretty fair chance that the primary payer has already paid more than Medicaid allows, no matter which code was used, so it may end up being a write off no matter which way you go.

Also, you'll need to verify with your state Medicaid office that they will allow this same "crosswalk the code after a consult has been billed to primary" thing.

I'll try to find a link to Medicare's rule so you can have it to refer to.

HTH some!


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## mhstrauss (Mar 4, 2016)

mhstrauss said:


> I agree with what hopepg posted as one of your options. Other things to consider:
> 
> After Medicare made the decision to stop accepting consults, they put out guidance that, when Medicare is secondary to a commercial payer (or any payer that still accepts consults), the provider can either 1. bill a consult code to the primary payer, then once claim is paid crosswalk the consult to an appropriate new/estab E/M code, and file that to Medicare secondary with the primary EOB. OR 2. not use the consult code at all, just file a new/estab E/M to both payers, which is easier in the long run, but you'll possibly be missing out on reimbursement from the primary payer. Depending on the primary payer's fee schedule, this may or may not be the right decision for your practice. There's a pretty fair chance that the primary payer has already paid more than Medicaid allows, no matter which code was used, so it may end up being a write off no matter which way you go.
> 
> ...




Here's the link from Medicare--see the Q&A starting at the bottom of page 5:

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/se1010.pdf


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