Any suggestions for billing this code. CPT allow this code to be billed as multiple units with or without mod -59. Maryland Medicaid allows a max of 2 units per visit, however when billed, only one unit is paid? Any experiences/recommendations? Thanks!
With Maryland Medicaid you need to bill it 96110 x 2 units. Maryland Medicaid does not use modifier 59 for anything. You need to do the same with flu tests when you are doing the rapid tests for A and B. Bill 87804 x 2 units.
Any luck with Maryland Medicaid Managed Care Organizations (MCOs) billing CPT 96160 (self risk assessment screening tools ie Cudit-R, CAGE questionnaires) in multiple units?
I do not use that code with MCOs. I use the SBIRT “W” codes as listed at this link. https://mmcp.health.maryland.gov/epsdt/healthykids/AppendixSection6/Coding-Guidelines-for-Screening-Tools-Primary-Care-final.pdf
I have used CPT 96160 in the past with modifier 59. It does pay but the reimbursement is higher with the “W” codes. In addition, I found that Aetna Better Health is in the process of updating their system to accept the W codes. In that past they did not pay for either one. Since these W codes are Maryland Medicaid home grown codes, you need to check if your clearinghouse uploaded them in their system. I use Trizetto and they have the codes loaded. If not, the clearinghouse will be rejected. Many times the MCOs will update their claims processing software and the W codes get kicked out and they deny. At that point you need to contact the provider rep to get it fixed and run a claims project on that code.
I have a question for you. When you do the heel stick for the metabolic screening or the finger stick for the lead testing at the time of the physical, how do you bill for that to get paid for the services of collection, handling, and mailing the specimen to the lab. Medicaid no longer reimburses for 36416 and 99000. I do not bill for the test itself since I am not running the lab test in our office.
Thanks for the prompt reply.
MCOs reimburse for 1 unit of cpt 96160 with mod 59. Additional unit(s) are “bundled” under EM code or cpt 96127 (if also billed on the claim). We will shift to billing the W codes where appropriate. Our conundrum is the requirements for SDOH (Social Determinants of Health) patient screening using cpt 96160. This is paid by commercials but MCOs have a different set of rules.
Regarding blood draws/specimen prep for the outside labs. We do not draw or handle blood specimens. Yes, despite billing this code for YEARS, cpt 99000 is not reimbursed by the MCOs or MA:(
I see on the chart at the link that I sent you that there are limitations. If the MCO is not following the rules as per the chart, then you need to reach out to the provider rep with claims examples and the Medicaid coding guidelines for screening tools chart. If the MCO are not cooperative, then you can reach out to Healthchoice provider hotline. 800-761-8692 or MDH.Healthchoiceprovider@maryland.gov.