Medicaid Articles and Resources

Medicaid programs are available to anyone unable to afford private health insurance or unable to meet the requirements for Medicare benefits. Federal and state governments cooperate in financing the Medicaid program. Each state decides which Medicaid health services will be provided as covered benefits and how those benefits will be administered within their state. There are distinct differences between the way Medicare and Medicaid programs are administered as well as differences in coverage between individual states.

Your local state health department or state professional association can provide more specific information about how Medicaid is administered in your area. Interested healthcare providers should contact their state health departments for detailed information on this program.

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Oct 31st, 2024

Medicaid and Children’s Health Insurance Program (CHIP) Quality and Managed Care

Broadly speaking, managed care is a healthcare delivery system designed to control costs, improve quality, and manage how services are provided to enrollees. It integrates healthcare providers, hospitals, and insurers to coordinate patient care in a cost-effective way. Managed care often emphasizes preventive care, streamlined service delivery, and coordinated treatment plans.

Oct 31st, 2024

What Medicaid Information is in Find-A-Code?

Oct 30th, 2024

What are the Different Medicaid Payment Systems?

The Medicaid payment system, which funds healthcare for low-income individuals and families, is complex and varies by state. It generally works through a combination of fee-for-service (FFS) and managed care models, with federal and state governments sharing costs. This article contains information to help explain some of the different ways that Medicaid pays for healthcare services.

Oct 30th, 2024

What is the Medicaid Chronic Illness and Disability Payment System (CDPS)?

The Medicaid Chronic Illness and Disability Payment System (CDPS) is a diagnostic-based risk adjustment model used to calculate payments for Medicaid health plans, particularly for those covering individuals with chronic illnesses and disabilities.

Oct 31st, 2022

CMS Updates COVID Vaccine Requirements for Staff

by Wyn Staheli, Director of Content - innoviHealth

CMS is revising its guidance and survey procedures for all provider types related to assessing and maintaining compliance with the staff vaccination regulatory requirements. This new memorandum replaces memoranda QSO 22-07-ALL Revised, QSO 22-09-ALL Revised, and QSO 22-11-ALL Revised.

Oct 15th, 2021

Is Your Organization Ready to Deal with Provider Relief Fund (PRF) Audit Contractors?

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Audits are currently underway to verify the monies distributed through the CARES Act were warranted and properly used by those organizations that received them. The federal government has contracted with financial institutions such as KPMG and PricewaterhouseCoopers, among others, to perform these audits referred to as Provider Relief Fund (PRF) audit contractors, funded with monies from the very same program. There were four phases of funding disbursements with phase 1 audits beginning in September. How ready are you to be audited?

May 6th, 2021

Identifying Risk-Adjusted Services During the Opioid Crisis

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Between June 2019 and June 2020, the United States saw a total of 107,750 deaths from COVID-19. The spread of this virus was so extraordinary that it led President Trump to declare a public health emergency, and we watched as individual states began implementing laws and regulations to limit social interaction ...

Apr 19th, 2021

Q/A: For E/M, How do I Count Tests Ordered in One Department and Performed in Another?

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Question: I am in an ENT office as part of a large clinic with separate practices including audiology, CT, and allergy, all billing under the same TAX ID. Sometimes tests are ordered which are done in other departments that my office does not bill for, would those be considered an outside source? Answer: This is a great question and one that has been asked by many coders and auditors.

Mar 18th, 2021

How Reporting E/M Based on Time May Lose Money

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's ...

Oct 20th, 2020

CMS Expands Telehealth Again

by Wyn Staheli, Director of Content - innoviHealth

On October 14, 2020, CMS announced further changes to expand telehealth coverage. Eleven (11) new codes have been added to their list of covered services bringing the current total to 144 services. The new services include some neurostimulator analysis and programming services as well as some cardiac and pulmonary rehabilitation services.

Apr 20th, 2020

Dismal OIG Report on Telemedicine

by Wyn Staheli, Director of Content - innoviHealth

Providers need to understand the rules for reporting telemedicine services. A recent OIG report shows that this is not the case. What problems are being found in documentation claims? As providers are expanding their telehealth offerings, now is the time to understand the potential pitfalls since disallowed amounts will be taken back.

Apr 15th, 2020

New CPT® Codes Approved for COVID-19 Antibody Identification

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

On April 10, 2020, the American Medical Association approved and published a revision of code 86318 and added two new codes 86328 and 86769 for reporting Coronavirus [COVID-19] antibody testing.

Mar 24th, 2020

"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Do you still find yourself searching the internet for an ICD10 code? Medical coders often type into their search engine, what is the ICD10 code for ... and a specific diagnosis code, to avoid repeatedly dragging out the incredibly large ICD10 codebook. Ironically, some of the most commonly searched ICD10 diagnoses include: ...

Mar 21st, 2020

Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)

by Aubrie Rowley

The current coronavirus pandemic refers to COVID-19, a novel or new type of coronavirus known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The first victim of the virus was identified in Wuhan, Hubei, China at the end of 2019. There is no immunization available to prevent it from spreading and ...

Oct 1st, 2019

Do ICD-10 Updates Have Your Heart Beating Irregularly? Check Out the New Atrial Fibrillation Codes

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Atrial fibrillation (AF) is the most common type of abnormal heart rhythm (arrhythmia). It is caused by a disorder in the heart’s electrical system. AF is the result of abnormal contractions of the atria (upper two chambers of the heart) causing them to quiver and beat out of sync with ...

Jun 13th, 2019

What Medical Necessity Tools Does Find-A-Code Offer?

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...

May 29th, 2019

Noting "Noncontributory" for Past Medical, Family, Social History - Is It Acceptable?

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Is "noncontributory" really an unacceptable word to describe a patient whose family history doesn't have any bearing on the condition being evaluated and treated today?

Apr 23rd, 2019

Let's Talk High Risk E/M Services

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services. Both the American Medical Association and Medicare-published E/M Guidelines agree that a ...

Apr 23rd, 2019

What is Medical Necessity and How Does Documentation Support It?

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

We recently fielded the question, “What is medical necessity and how do I know if it's been met?" The AMA defines medical necessity as: It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...

Mar 21st, 2019

The Impact of Medical Necessity on High Level E/M Services

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?" The quick answer is, "it depends." Code 99233 has the following minimal component requirement: Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...

Mar 18th, 2019

How to Report Imaging (X-Rays) of the Thumb

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

If you've ever taken piano lessons, you know that the thumb is considered the first finger of the hand. Anatomically, it is also referred to as the first phalanx (finger). However, when you are coding an x-ray of the thumb, images are captured of the thumb, hand, wrist, and all ...

Mar 1st, 2019

Understanding NCCI Edits

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...

Feb 11th, 2019

HHS Proposes Significant Changes to Patient Access Rules

by Wyn Staheli, Director of Content - innoviHealth

In a significant announcement on February 11, 2019, HHS proposed new rules aimed at improving interoperability of electronic health information. This announcement was made in support of the MyHealthEData initiative which was announced by the Trump administration on March 6, 2018. The goal of that initiative was to break down ...

Jan 23rd, 2019

How to Report Co-Surgeons Using Modifier 62

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session. An easy way to explain this is to visualize a patient requiring cervical fusion where ...

Jan 4th, 2019

Nine New Codes for Fine Needle Aspirations (FNA) in 2019

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

If your practice performs a lot of fine needle aspirations (FNA), you probably have the code options memorized (10021 without image guidance and 10022 with image guidance). However, the 2019 CPT codes now include nine (9) new FNA codes (10004-10012), one deleted FNA code (10022) and one revised FNA code ...

Oct 17th, 2018

Wolters Kluwer Drug Pricing

by Find-A-Code™

Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...

Jul 18th, 2018

Provider-Based Facilities and Split Billing: Is Your Facility Being Reimbursed for All Work Performed?

by Brandon Herman, QMC QMCC QMBHC QMPM QMPoC

Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed. For ...

Jul 12th, 2018

Dual Medicare-Medicaid Billing Problems

by Wyn Staheli, Director of Content - innoviHealth

It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added): A state plan must provide ...

Sep 14th, 2017

Double Dipping in the History of the Evaluation and Management Note

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them. Double dipping occurs when the same information is used in more than one of the subcomponents of history. The subcomponents of history include: Chief Complaint ...

Feb 6th, 2017

Medicaid EHR Incentive

by Wyn Staheli, Director of Content - innoviHealth

The Medicare and Medicaid incentive programs are different. The Medicare EHR incentive program has been incorporated into the new Quality Payment Program (QPP). However, providers may be unaware that there is still a Medicaid EHR incentive program. The time period for signing up for the Medicaid EHR incentive program ended in 2016. ...

Dec 12th, 2016

60 Day Final Rule

by Wyn Staheli, Director of Content - innoviHealth

Effective March 14, 2016, the CMS Final Rule clarifying the standards for handling overpayments for both Medicare and Medicaid takes effect. Failure to report and subsequently return an overpayment within 60 days after the overpayment was “identified” is a violation of the False Claims Act.

Apr 13th, 2016

Telehealth Basics

by Wyn Staheli, Director of Content - innoviHealth

Telehealth and telemedicine are covered for many payers for services such as consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system.

Feb 1st, 2016

Will Incident-To in Your Organization Pass a Compliance Audit?

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Practices that bill incident to services need to periodically audit compliance with Medicare and private payor guidelines to avoid potential denials or third-party audits.

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Jun 17th, 2019

Telehealth Policies for Medicare and Commercial Payers

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