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MediCal Payments (Northern California)

Tierni Posted Tue 03rd of September, 2019 13:15:15 PM
Hello. We have always been told MediCal pays a claim with multiple lines at a descending rate. However, I can not find any supporting evidence of this. Example: A claim has two lines. MediCal pays line 1 at 100%, and line 2 at 50%. Do you know if this is true, and if so, where I can find their policy regarding this? If this is true, then it would be safe to assume you'd always put the CPT's in their highest RVU/Pricing order. Thank you for the help!!!
SuperCoder Answered Wed 04th of September, 2019 08:08:30 AM

When billing multiple procedure codes performed on the same day of service, on the same patient by the same physician, codes should always be listed according to their assigned descending RVUs. This sequencing is important when it comes to reimbursement, because if a lesser RVU code is billed first, it will be reimbursed fully while the higher RVU code will be paid at a reduced rate thus lowering the total reimbursement. But, if your procedures are un-related than the other procedure and no modifier is applicable, then it will be reimbursed fully. Mostly modifier 51 (Multiple Procedure) is used to subsequent procedures, e.g., the second, third, fourth procedure, if the same provider performs multiple procedures for the same patient during the same encounter.

Appending modifier 51 to the second or third procedure tells the payer that the provider performed multiple procedures in the same operative session. The insurance typically reduces payment for each procedure after the first one performed. One way you can look at modifier 51 is to think of it as an informational modifier for use on the second, third, etc., surgical procedure performed on the same day. Processing claims electronically allows the carrier to recognize when your physician performs multiple procedures and automatically make the necessary reduction in payment. However, some smaller payers may require the use of this modifier. Before you submit your claim, you should contact your insurance carrier for the policy and ask which method it would prefer when reporting multiple surgical procedures.

Be sure to report the most complex procedure first, for the highest dollar amount, on the claim form. Some payers typically reimburse the most for the most expensive procedure and will reduce payment for subsequent procedures with lower charges that you report with modifier 51.

Do not report modifier 51 with modifier 50, with add–on codes, with codes that are modifier 51 exempt, or with bilateral procedures. Do not use modifier 51 with E/M services, physical medicine and rehabilitation services, or with supplies.

Hope this helps!

Tierni Posted Wed 04th of September, 2019 11:54:49 AM
Thank you for this information. Where did you get this information from? I would like to review myself.
Tierni Posted Wed 04th of September, 2019 13:13:25 PM
Please Note: I'm not questioning the modifier information. I want to see supporting documentation on the payment breakdown you provided. Thank you.
SuperCoder Answered Thu 05th of September, 2019 04:15:14 AM

Hi Tierni,

Hope you are keeping good.

We encourage discussion to enhances the knowledge which impart lifelong. So, do not hesitate to ask any related question.

Well, you can find the related information related to modifier on the SuperCoder's modifier detail page. On this page you can refer, Lay Term (Modifier Details, Modifier Explanation and Tips), Modifier Guidelines and Related Articles.

Also, for general coding guidelines, you can check this on the Medicare site at the following link:

Specifically refer the page no. 14.

Since, your payer is MediCal (Northern California), if they are following the general coding guidelines, then you can refer the Medicare guidelines. On the other hand, for Payer Specific Guidelines, you have to get in touch MediCal.

Hope this helps!

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