Are you aware that Iowa Medicaid is denying payment for emergency physician services based on final diagnosis? Despite the fact that all payers are to use the “prudent layperson” definition to determine if emergency care is necessary, Iowa Medicaid is using the final diagnosis to determine if payment should be made.
The “prudent layperson” definition is: An emergency service is any health care service provided to evaluate and/or treat any medical condition such that a prudent layperson possessing an average knowledge of medicine and health, believes that immediate unscheduled medical care is required.
So, after you see and evaluate that chest pain patient, use your medical knowledge and skills to rule out the most serious considerations (ie, AMI, PE, Pneumothorax, dissecting aneurysm, etc), and have a final diagnosis of costochronditis, Iowa Medicaid denies payment for your services.
Please see the attached list of diagnosis codes that Iowa Medicaid will reimburse. Go to the website and then scroll down to Emergency Diagnosis Codes. These are not CPT codes, but strictly final diagnosis codes. There are over 3,300 diagnoses here, including multiple sprains / dislocations / fractures, over 150 types of burns, more than 130 types of poisonings and nearly 40 types of myocardial infarctions. “Chest pain” is a diagnosis that Iowa Medicaid will reimburse.
The Washington State ACEP Chapter presented legislation this past year to address similar concerns. This past weekend, the Governor of California signed legislation that California ACEP proposed that included prudent layperson language for Medicaid fee-for-service claims.
Iowa ACEP has formed a Task Force to investigate this further. But WE NEED YOUR HELP!
Please let us know about any claim denials or issues you are having with reimbursement of emergency medicine services. And let us know if you are interested in serving on the Task Force.
Stay tuned for more information.