How do I code this?

Report
2014 REIMBURSEMENT UPDATE
IMPACT ON EDUCATION AND CLINICAL
PRACTICE FOR COMMUNICATION SCIENCES
AND DISORDERS- PART ONE
Dee Adams Nikjeh, Ph.D., CCC-SLP
1
Annual CAPCSD Conference
April 10, 2014
DISCLOSURES
 Dee
Nikjeh has financial relationships to disclose
Mileage and one-night’s stay are covered for this
presentation
 She is a paid consultant for the U.S. Department of Justice
to investigate Medicare fraud

 Dee
Nikjeh has nonfinancial relationships to
disclose
She is Co-Chair of ASHA’s Health Care Economics
Committee
 She is advisor to the American Medical Association’s
Relative Value Update Committee/Health Care
Professionals Advisory Committee

2
AGENDA

Two Health Care Coding Systems
Which is what? (CPT and ICD)
 What are the principles of coding?


2014 Medicare Physician Fee Schedule
How do procedures get a value and a fee?
 What factors in 2014 will affect fee payment?


Four New SLP Evaluation Procedure codes
How do we use modifiers and edits appropriately for these new
procedures?
 How are these procedures used in place of CPT 92506?


Professional Work
What defines skilled care?
 What is S.M.A.R.T. documentation?

3
TWO HEALTH CARE CODING SYSTEMS
4
Understanding the coding systems is
essential in any discussion of
reimbursement and coding.
TWO HEALTH CARE CODING SYSTEMS

Procedural Codes – Describe what we DO with the
client/patient


Current Procedural Terminology, a.k.a. CPT codes
Diagnostic Codes – Describe the REASON we are
evaluating or treating the client/patient

International Classification of Diseases, 9th Revision,
Clinical Modification, a.k.a. ICD-9 codes
Understanding the Codes
5
INTERNATIONAL CLASSIFICATION OF
DISEASES, NINTH REVISION, CLINICAL
MODIFICATION (ICD-9-CM)
ICD-10 POSTPONED…AGAIN…
6
INTERNATIONAL CLASSIFICATION OF DISEASES, 9TH
REVISION, CLINICAL MODIFICATION (ICD-9-CM)
Numeric classification system of diseases and disorders
 Chapters are based primarily on body systems (e.g.,
circulatory, respiratory, nervous)
 Code or codes to describe the problem or reason for our
procedure
 Issued by the U.S. Department of Health and Human
Services
 Approximately 15,000 codes

7
RESOURCES
ICD-9-CM Codes for SLPs:
www.asha.org/practice/reimbursement/coding/icd9
SLP.htm
 Guidelines for Coding & Reporting ICD-9-CM:
www.cdc.gov/nchs/data/icd9/icdguide.pdf
 ICD Home Page: www.cdc.gov/nchs/icd9.htm
 Questions: e-mail [email protected]

8
ICD-10-CM
BEGINS OCTOBER 1, 2015

ICD-10 includes approx 160,000
ICD-10-CM diagnosis codes for all settings (> 68,000)
 ICD-10-PCS procedure codes for hospital inpatients

Greater specificity3-7 alphanumeric characters instead
of 3-5 digits (ICD-9-CM)
 Code descriptors have more detail, less room for error
 Combination codes represent disease & systems
 Clearer instructions than ICD-9-CM
 Accommodate current, complex, and future health care
needs

9
INTERNATIONAL CLASSIFICATION OF DISEASESCLINICAL MODIFICATION (ICD-CM)

Purpose
Standardize disease and procedure classification
throughout the US
 Gather data about basic health statistics and trends
 Code and classify mortality data from death certificates

Clinical Modification – Developed by Center for
Disease Control and Prevention (CDC)
 Owned by the World Health Organization (WHO)

10
PRINCIPLES OF ICD CODING
Code to the highest degree of medical certainty or
specificity
 Avoid Not Otherwise Specified (NOS) and Not
Elsewhere Classified (NEC)Codes
 Primary diagnosis is condition (disease, symptom,
injury) chiefly responsible for visit or reason for
encounter
 Secondary diagnoses is co-existing conditions or
symptoms, or condition found after study
 If results of diagnostic testing are NORMAL, code
signs or symptoms to report the reason for
test/procedure and explain normal result in report
 The procedure (CPT code) should be appropriate for
the condition or reason (ICD code) for encounter

11
ICD-9 TO ICD-10
ASHA MAPPING TOOLS

Online Mapping Tools for ICD-9 to ICD-10 codes
Enter the ICD-9 code and a list of the corresponding ICD10 codes is generated
 Mapping Spreadsheet to view related mappings in one list

A list of SLP and AUD ICD-10 codes, much like the
current ICD-9 list on the ASHA website
 Products are free and tailored for speech-language
pathology and audiology

12
ASHA ICD-9 TO ICD-10 MAPPING TOOL
315.39
13
ASHA ICD-10 MAPPING TOOL
14
EXAMPLES OF ICD-10-CM FOR SLP

F80.1 Expressive language disorder

F80.81 Childhood onset fluency disorder

F80.4 Speech and language development delay due to hearing loss

I69.020 Aphasia following nontraumatic subarachnoid hemorrhage

I69.120 Aphasia following nontraumatic intracerebral hemorrhage

I69.320 Aphasia following cerebral infarction

R13.11 Dysphagia, oral phase

R41.841 Cognitive communication deficit

R48.8 Other symbolic dysfunctions

R49.21 Hypernasality
15
ICD-10: QUESTIONS FOR CMS
Will Oct. 1, 2015, become the new deadline?
 Will the agency allow organizations that are ready to
implement ICD-10 to do so voluntarily?
 Will agency scrap ICD-10 altogether and instead, wait
for ICD-11 which is due to e released in 2017?

16
RESOURCES
ICD-10-CM
ASHA Website for ICD-10
www.asha.org/Practice/reimbursement/coding/ICD10/
 ICD-9 to ICD-10 ASHA Mapping Tool
www.asha.org/icdmapping.aspx
 National Center for Health Statistics Website:
www.cdc.gov/nchs/icd/icd10cm.htm
 Centers for Medicare & Medicaid Services Website:
www.cms.gov/ICD10/

17
2014 CPT
“… a set of codes, descriptions, and
guidelines intended to describe
procedures and services performed by
physicians and other health care
providers.”
18
CURRENT PROCEDURAL TERMINOLOGY
AKA CPT CODES
 Every
medical, surgical, and diagnostic procedure
assigned a 5-digit code
 CPT codes are used to


Simplify the reporting of services
Ensure uniformity of communication
 Approximately 8,000 codes
 Developed, maintained,
and copyrighted by the
American Medical Association (AMA)
 Updated annually
19
RELATIVE VALUE UNIT (RVU)
 Every
CPT procedure or service has a resourcebased relative value
 Payments for services are determined by the
resource costs needed to provide them
 3 components make up a relative value



Professional work
Practice expense
Professional liability insurance
 All
procedures are ranked on this same scale
 Standardized physician payment schedule
20
MEDICARE IMPROVEMENTS FOR PATIENTS AND
PROVIDERS ACT OF 2008 (MIPPA)
MIPPA – Effective July 1, 2009
 Granted SLPs independent billing to Medicare
 Changed our status with CMS to a Medicare Provider
 Recognized SLPs as professionals rather than technical
assistants
 Allowed for the “relative value” of SLP CPT (procedure)
codes to be re-valued to include a professional work
component

21
THREE COMPONENTS OF
RELATIVE VALUE UNIT
*Professional
Work*
Time it takes to perform the service
 Technical skill and physical effort
 Required mental effort and judgment
 Stress due to the potential risk to the patient


Practice Expense
Time of support personnel**
 Supplies
 Equipment
 Overhead


Professional Liability/Insurance Costs
22
2014
MEDICARE PHYSICIAN FEE SCHEDULE
23
Extended through March 31, 2015
MEDICARE PHYSICIAN FEE SCHEDULE

RVU X Monetary Conversion Factor = Medicare Payment per
Procedure

Payment adjusted for geographic location

Conversion Factor for 2013 = $34.0376

Conversion Factor for 2014 = $35.8228
•
0.5% increase
•
Pathway for SGR Reform Act of 2013 – Law 12-26-13
24
25
www.asha.org/practice/reimbursement/medicare/feeschedule/
FACTORS AFFECTING PAYMENT SCHEDULE
Conversion Factor
 Sustainable Growth Rate (SGR)
 Therapy Cap and Medical Manual Review
 Sequestration
 Multiple Payment Procedure Reduction
 Geographic location

26
CONVERSION FACTOR - WHAT’S THAT ?
…OR WHAT WAS THAT?

CF based on the Medicare Sustainable Growth Rate (SGR)
SGR enacted by the Balanced Budget Act of 1997
 Method used by CMS to control Medicare spending by
physician services
 CF recommended to Congress by CMS

CF changes payments for physician services for the next
year in order to match the targeted SGR
 If expenditures for previous year exceeded targeted
expenditures, then conversion factor decreased payments
for the next year and vice versa
 Despite CMS recommendations for major cuts to the CF,
Congress has not changed CF since 2011
27

SUSTAINABLE GROWTH RATE
REPEALED ? REFORMED? REPLACED?

March 31, 2014 - 12-month patch
Extends current 0.5% update through the end of 2013
 Freezes payment rates until March 31, 2015
 Extends Therapy Cap
 Extends Post-payment Manual Medical Review

Senate and House agree on Repeal but not on the details
 Congress has passed 17 such patches over past 11 years

28
MERIT-BASED INCENTIVE PAYMENT SYSTEM
(MIPS) – LOOKING TO THE FUTURE
 Incentive
payment program that will focus the
fee-for-service system on providing value and
quality on patient performance
Quality measures
 Resource use
 Clinical practice improvement activities
 Electronic Health Record meaningful use

 May
professionals with the opportunity to
receive additional payment adjustments
through use of this merit-based system
 Stay tuned…more to come
29
MANUAL MEDICAL REVIEW OF THERAPY SERVICES
CONTINUES AT LEAST UNTIL APRIL 1, 2015

Therapy cap of $1,920 continues for combined PT and
SLP

Continue to use the KX modifier at $1,920 limit

Exceptions Process – For Medicare Part B therapy
services that exceed the $3,700 threshold the postpayment (all states) manual medical review continues

Resources

Ingrida Lusis, ASHA's director of federal and political
advocacy, at [email protected]

Questions related to the therapy cap exceptions process,
should be directed to [email protected]
30
MULTIPLE PROCEDURE PAYMENT REDUCTION (MPPR)
Reduces practice expense (PE) payment for second
and subsequent procedures provided on the same
day to the same patient for Medicare Part B services
 Expanded to therapy services in 2011



50% decrease in PE fees for Part B services in all settings
New SLP evaluation procedure codes are included in
MPPR
31
SEQUESTRATION
2% reduction on the 80% Medicare payment
continues
 No end in sight for this…

32
CPT 92506
EVALUATION OF SPEECH, LANGUAGE, VOICE,
FLUENCY, COMMUNICATION AND/OR AUDITORY
PROCESSING
33
“Please describe the typical patient
and explain to us exactly what you do for
procedure 92506.”
FOUR NEW SLP EVALUATION PROCEDURE CODES REPLACE
CPT 92506 JANUARY 1, 2014
92521 - Evaluation of speech fluency (e.g., stuttering,
cluttering)
 92522 - Evaluation of speech sound production (e.g.,
articulation, phonological process, apraxia, dysarthria)
 92523 - Evaluation of speech sound production (e.g.,
articulation, phonological process, apraxia, dysarthria)
with evaluation of language comprehension and
expression (e.g., receptive and expressive language)
 92524 - Behavioral and qualitative analysis of voice and
resonance

34
CPT 92521 - EVALUATION OF SPEECH FLUENCY
(E.G., STUTTERING, CLUTTERING)
Vignette for CPT 92521
A 7-year-old male presents with stuttering that includes
behavioral (e.g., repetitions, prolongations, and blocks) and
affective (e.g., avoidance and/or reduction of
communication interaction) responses that negatively
impact his communication function.
35
CPT 92522 - EVALUATION OF SPEECH SOUND PRODUCTION (E.G.,
ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)
Vignette for CPT 92522
A 6-year-old male presents with age-appropriate language
comprehension and expression; yet, his speech sound
production is unintelligible and negatively impacts his
abilities to successfully communicate with others.
36
CPT 92523 - EVALUATION OF SPEECH SOUND PRODUCTION (E.G.,
ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)
WITH EVALUATION OF LANGUAGE COMPREHENSION AND
EXPRESSION (E.G., RECEPTIVE AND EXPRESSIVE LANGUAGE)
Vignette for CPT 92523
A 5-year-old male presents with significant deficits of
receptive, expressive, and social language and highly
unintelligible speech sound production that limit his
abilities to understand and communicate effectively in daily
social and educational activities with family and peers.
37
CPT 92524 - BEHAVIORAL AND QUALITATIVE ANALYSIS OF
VOICE AND RESONANCE
Vignette for CPT 92524
A 38 year-old female diagnosed with bilateral vocal cord
nodules was referred for an evaluation of functional voice
use and resonance to facilitate the design of a voice
therapy/behavioral treatment plan. The patient complains
of progressive hoarseness, inadequate projection, altered
resonance, vocal fatigue, and tightness and pain in her
throat which compromises her ability to communicate
effectively.
38
WHY IS THERE NOT A LANGUAGE-ONLY EVALUATION
PROCEDURE CODE?





Language-only evaluation for children is rare in the absence of
speech sound production
 Survey of practices/clinics confirmed that this occurs less
than 20% of the time
However, speech-sound production commonly evaluated in
absence of language testing
If two or more procedures are billed together greater than 51%
of the time, CMS considers them to overlap and will bundle the
procedures and decrease the reimbursement
If evaluating only language, may code 92523 with the
-52 modifier* indicating reduced service
Keep in mind SLPs have evaluation procedure codes for
standardized cognitive assessment, developmental assessment,
and aphasia
39
BILLING CODES TOGETHER?





Sometimes it is appropriate for more than one disorder to be
evaluated on the same day or for more than one procedure to be
billed on the same day
Documentation should clearly reflect a complete and distinct
evaluation for each disorder
Evaluation codes should not be billed for brief assessments that
could be considered screenings
Time for identification of other disorders is already built into
the value of each code
Inappropriate use of multiple evaluations on same day will
result in restrictions through the National Correct Coding
Initiative (CCI) edits
40
Coding Clarification
EDITS AND MODIFIERS
41
CODING CLARIFICATIONS - EDITS
ο Two types of similar edit systems depending on
setting
ο National Correct Coding Initiative (CCI) – any
Part B services not rendered in a hospital
ο Outpatient Code Editor (OCE) – outpatient hospital
services
ο Automated edit systems used by CMS to control
specific CPT code pairs that can be reported on the
same day for the same patient
ο CCI is updated quarterly and OCE follows one
quarter later
ο Since late 2010, CCI also applies to Medicaid per
federal law
42
CODING CLARIFICATIONS-EDITS



Some procedures considered to be “mutually exclusive”
and may not be billed together for the same patient on the
same day
Examples for SLP
 92607 (Speech-generating device evaluation) & 92597
(Voice prosthetic evaluation)
 92507 (Speech, lang tx) & 97532 (Cog tx)
 92522 (Speech eval) & 92523 (Speech & Lang eval)
SLP CCI Edits can be found at
www.asha.org/practice/reimbursement/coding/CCI_edits
_SLP.htm
43
MEDICALLY UNLIKELY EDITS (MUES)
Subset of CCI edits also for Medicare Part B and
Medicaid claims
 Specifies maximum number of times that a CPT code
can be reported on same day for same patient
 Separate MUEs for office and hospital outpatient
settings, but SLP MUEs are similar for both

92507
 92526
 96105
 96125


1
1
3
2
speech tx
dysphagia tx
aphasia assessment per hour
cognitive performance testing per hour
For a complete list of SLP-related MUEs, see:
www.asha.org/Practice/reimbursement/coding/Medi
cally-Unlikely-Edits-SLP/
44
CODING CLARIFICATION
SPECIAL CIRCUMSTANCES- MODIFIERS

-59 Indicates Distinct Procedural Service



Only modifier used with NCCI edits
For two procedures not ordinarily performed on the same day
by the same practitioner, but which, under certain
circumstances, may be appropriate to perform and therefore
code on the same day (e.g., different site or organ system)
Who provides the service
GN: Speech-language pathologist
 GO: Occupational therapist
 GP: Physical therapist


Severity Level Modifiers with G-codes for functional claims
45
reporting
EXAMPLES OF MODIFIERS
SOMETIMES USED BY SLPS

“-52” indicates an abbreviated procedure

“-59” indicates that two procedures are distinct and
separate



CPT 92611 (MBS) & 92610 (Clinical Swallow Eval)

CPT 92526 (Dysphagia tx) & 97532 (Cog tx)

CPT 92508 (Group tx) & 92507 (Indiv tx)

CPT 96105 (Aphasia assessment) & 96125 (Cognitive Performance
testing)
“-22” indicates a much longer than usual procedure
46
“-76” indicates a repeat procedure by the same provider on
the same date of service
ASHA CCI EDIT PAGE FOR SLP CODES
47
www.asha.org/practice/reimbursement/coding/CCI_edits_SLP.htm
ASHA RESOURCES
ᴏ Manual Medical Review
ᴏ www.asha.org/Practice/reimbursement/ExceptionProcess/
ᴏ Medicare Physician Fee Schedule
ᴏ www.asha.org/practice/reimbursement/medicare/feeschedule/
ᴏ National Correct Coding Initiative (CCI Edits)
ᴏ www.asha.org/practice/reimbursement/coding/CCI_edits_SLP.htm
ᴏ Medically Unlikely Edits (MUEs)
ᴏ www.asha.org/Practice/reimbursement/coding/Medically-UnlikelyEdits-SLP/
48
NEW SLP EVALUATION CODES
QUESTIONS AND ANSWERS
49
CPT 92521
CPT 92522
CPT 92523
CPT 92524
SCENARIO 1: SLP CPT QUESTION

May I bill CPT 92522 and 92523 together on the same
day?


CPT 92522 - Evaluation of Speech-sound production (e.g.,
articulation, phonological process, apraxia, dysarthria)
CPT 92523 - Evaluation of speech sound production (e.g.,
articulation, phonological process, apraxia, dysarthria) with
evaluation of language comprehension and expression (e.g.,
receptive and expressive language)
50
SCENARIO 1: SLP CPT ANSWER
No, do NOT Code these two together, only one or the other
 CPT 92523 INCLUDES the evaluation of speech sound
production

51
SCENARIO 2: SLP CPT QUESTION

When I evaluate a child who has a cleft palate and
speech and language problems, what procedures
may I code?
52
SCENARIO 2: SLP CPT ANSWER

CPT 92523 Speech-sound production (e.g., articulation,
phonological process, apraxia, dysarthria); with
evaluation of language comprehension and expression
(e.g., receptive and expressive language)

CPT 92524 Behavioral and qualitative analysis of voice
and resonance
53
SCENARIO 3: SLP CPT QUESTION

I evaluate an adult with a voice disorder, using the
new procedure code CPT 92524 (Qualitative and
behavioral analysis of voice and resonance). Patient
has no resonance disorder.

Do I code CPT 92524 with -52 modifier to indicate
a shortened evaluation?
54
SCENARIO 3: SLP CPT ANSWER
-52 modifier is not required if only voice or only resonance
is evaluated
 Descriptor of CPT 92524 is written so that voice and/or
resonance may be evaluated
 Recommend a statement of observation that one or the
other is not impaired
 Code developed so that those who work with cleft palate
have appropriate choices of procedure codes

55
SCENARIO 4: SLP CPT QUESTION

I am evaluating a patient who has Parkinson’s
disease. He has dysarthria and a voice impairment.
May I do more than one evaluation procedures
and which procedures codes may I use?
56
SCENARIO 4: SLP CPT ANSWER
YES
 CPT 92522 Speech-sound production(e.g.,
articulation, phonological process, apraxia,
dysarthria)
 CPT 92524 Qualitative and behavioral analysis of
voice and resonance
 Document completely including your
recommendations for plan of care based on your two
evaluations

57
SCENARIO 5: SLP CPT QUESTION

I am evaluating a patient who is referred because
of cognitive impairment. I used to code CPT
92506. What should I do now?
58
SCENARIO 5: SLP CPT ANSWER

You may use CPT 96125 (Standardized cognitive performance testing,
per hour) for evaluation of cognitive skills and abilities

CPT 96125 is a per hour code which requires at least 31 mins for one
hour or 91 to 151 mins for two hours of billing. This includes
administration and documentation. Standardized and nonstandardized
subtests may be included in the battery of measurement tools.

Cognitive assessment using informal tools and lasting less than the 31
mins may be considered a screening and payment may be denied.

For language only, possible to code 92523 with -52 modifier. Caution:
Value for shortened procedure has not been established.
59
SCENARIO 6: SLP CPT QUESTION

What if I provide both a cognitive assessment AND
a speech sound production with language
evaluation? How do I code this?
60
SCENARIO 6: SLP CPT ANSWER




Few circumstances (e.g., child with language-learning disorder)
may warrant both complete cognitive evaluation (CPT 96125)
and evaluation of speech-sound production with receptive and
expressive language (CPT 92523).
If you complete both a full cognitive evaluation and a
comprehensive speech & language evaluation, you may bill CPT
96125 AND 92523 with -59 modifier on 96125
Documentation must show separate and distinct procedures
Combine with CAUTION; Cognitive treatment (97532) and
speech and language treatment (92507) may NOT be billed
together on the same day to same patient b/c of overlap
61
SCENARIO 7: SLP CPT QUESTION

What if it takes two visits to complete CPT 92523
(speech sound production with language
evaluation) and then 45 minutes to interpret and
complete documentation? Can I bill CPT 92523
for 3 visits?
62
SCENARIO 7: SLP CPT ANSWER
No, CPT 92523 is not a timed code and may only be
billed once.
 The value of the code includes 120 minutes of intraservice time.
 Recommend to complete as much of the evaluation as
possible on the initial visit and if necessary, complete
the additional tests and measures during the
subsequent treatment sessions.

63
SCENARIO 8: SLP CPT QUESTION

I see a child for a speech fluency evaluation and also
perform an oral peripheral examination.

Can I bill CPT92521 (Evaluation of speech
fluency) and 92522 (Evaluation of speech sound
production)?
64
SCENARIO 8: SLP CPT ANSWER
No.
 An oral peripheral examination is an integral part of
every speech, language, fluency, and voice evaluation
and the time spent on the examination of is already
built into each evaluation code.

65
SCENARIO 9: SLP CPT QUESTION

What do I code for reevaluations?
66
SCENARIO 9: SLP CPT ANSWER
 Because
evaluations are provided for children and
adults who have communication impairments and
much of our testing is standardized to establish
basal and ceilings, age norms, percentiles, etc., the
reevaluation is just as detailed as the initial
evaluation.
 For that reason, SLPs do not have reduced
reimbursement for reevaluations.
 Document your evaluation findings and compare to
previous evaluation
67
RE-EVALUATION
WHEN IS IT APPROPRIATE?


A formal re-evaluation is covered if documentation supports need for
further tests and measurements after initial evaluation
Indications for a re-evaluation




Re-evaluation is focused on





Evaluation of progress toward current goals
Making a professional judgment about continued care
Modifying goals and/or treatment
Terminating services
Re-evaluation may be appropriate



New clinical findings,
Significant change in the patient's condition,
Failure to respond to therapeutic interventions outlined in plan of care.
Prior to discharge to determine whether goals have been met
For use by physician or treatment setting where treatment will be continued
Continuous assessment of patient's progress is a component of ongoing
therapy services and not payable as a re-evaluation
220.3 - Documentation Requirements for Therapy Services
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)
68
SCENARIO 10: SLP QUESTION

What do I code if I do a pediatric language-only
evaluation?
69
SCENARIO 10: SLP ANSWER




In the atypical evaluation when only a child’s language is
evaluated, SLPs may bill 92523 with the -52 modifier, which is
used to indicate a shortened procedure compared to the full
description of the service.
CAUTION: There is no established value for a shortened
procedure
CPT 96125 (Standardized cognitive performance testing, per
hour) or CPT 96111 (Developmental testing -- includes
assessment of motor, language, social, adaptive, and/or cognitive
functioning by standardized developmental instruments with
interpretation and report) may be appropriate options
Recommend including evaluation of speech-sound production
70
SCENARIO 11: SLP CPT QUESTION

I am evaluating an adult who has a traumatic
brain injury and dysarthria. Which evaluation
procedures and CPT codes may I use?
71
SCENARIO 11: SLP CPT ANSWER

You may code CPT 96125 for cognitive assessment


This is a timed, per hour code
31 minutes is allowable for one hour
OR
 You may code CPT 96105 for aphasia assessment





This is a timed, per hour code
31 minutes is allowable for one hour
If rationale to support both, then put -59 modifier on 96125
You may code CPT 92522 - Evaluation of speech sound
production (e.g., articulation, phonological process, apraxia,
dysarthria)
Document each procedure with results, interpretation,
recommendations, etc.
72
SCENARIO 11 CONTINUED: QUESTION

What if that dysarthria has a phonatory
component? In addition to the cognitive
assessment and the speech-sound production
evaluation, may I also add a voice evaluation and
maybe also an acoustic and aerodynamic
assessment?
73
SCENARIO 11 CONTINUED: ANSWER
74
RESOURCES

For Medicare, get in touch with the Medicare
Administrative Contractor in your area. If you
continue to have problems, please contact ASHA's
health care economics and advocacy team
at [email protected]

Notifications and news items will be available
through ASHA Headlines and The ASHA Leader.
Specific questions can be directed to ASHA's health
care economics and advocacy team
at [email protected]
75
WHAT IS “SKILLED” TREATMENT?
WHAT IS “NONSKILLED” TREATMENT?
76
MEDICARE IMPROVEMENT STANDARD
CLARIFICATION
CMS - “Nothing in this Settlement Agreement modifies,
contracts, or expands the existing eligibility requirements
for receiving Medicare coverage.”
 Jan 24, 2013 – Federal judge ruled






CMS must allow coverage of therapy services that prevent or
slow deterioration
Therapy services must require skilled care
Coverage not dependent on potential for improvement
Outpatient services, Inpatient rehab, SNF, home health
Does not apply to CORFs b/c statue specifies “rehabilitative”
77
JIMMO V. SEBELIUS SETTLEMENT AGREEMENT
Coverage not dependent on potential for improvement,
but rather on the need for skilled care
 Skilled care may be necessary to improve a patient’s
current condition, to maintain the patient’s current
condition, or to prevent or slow further deterioration of
the patient’s abilities; e.g., carry out communication or
feeding activities
 Coverage is not available when the beneficiary’s
maintenance care needs can be addressed safely and
effectively through the use of nonskilled personnel (e.g.,
assistants, qualified personnel, caretakers or the patient).
 See www.cms.gov/Medicare/Medicare-Fee-for-Service- 78
Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf

PUB 100-02 MEDICARE BENEFIT POLICY, TRANSMITTAL 179
DATE: JANUARY 14, 2014
 Skilled
when
maintenance therapy may be covered
Patient’s special medical complications or complexity
of the therapy procedures require skilled care
 An individualized assessment of patient’s clinical
condition demonstrates that the specialized
judgment, knowledge, and skills of a qualified speechlanguage pathologist are necessary for the
performance of a safe and effective maintenance
program to maintain the beneficiary at maximum
practicable level of function
 http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R179BP.p
df

79
PROFESSIONAL SKILLED TREATMENT

“For patients with chronic or degenerative conditions,
evaluate patient’s current functional performance;
provide treatment to optimize current functional
ability, prevent deterioration, and/or modify
maintenance program” (Medicare Benefit Policy
Manual, Chapter 15, Section 220.2 C&D).
80
WHAT DOES A PROFESSIONAL DO?
Practice at the TOP of our license
 Clinical decision-making – using expert knowledge
 Develop and modify treatment and maintenance
programs
 Train, instruct and supervise others

81
PROFESSIONAL SKILLED TREATMENT
SPECIFICS
Analyze medical/behavioral data and select
appropriate evaluation tools/protocols to determine
communication/swallowing diagnosis and prognosis.
 Design plan of care (POC) including length of
treatment; establishment of long- and short-term
measurable, functional goals and discharge criteria.
 Develop and deliver treatment activities that follow
a hierarchy of complexity to achieve the target skills
for a functional goal.

http://www.asha.org/Practice/reimbursement/me
dicare/Documentation-of-Skilled-VersusUnskilled-Care-for-Medicare-Beneficiaries/
82
PROFESSIONAL SKILLED TREATMENT

Based on expert observation, modify activities during
treatment sessions to maintain patient motivation and
facilitate success.
Increase or decrease complexity of treatment task.
 Increase or decrease amount or type of cuing needed.
 Increase or decrease criteria for successful performance
(accuracy, number of repetitions, response latency, etc.).
 Introduce new tasks to evaluate patient’s ability to generalize
skill


Conduct ongoing assessment of patient response in order
to modify intervention based on:
patient performance in treatment activities;
 patient report of functional limitations and/or progress

83
PROFESSIONAL SKILLED TREATMENT
Engage patients in practicing behaviors while
explaining the rationale and expected results
and/or providing reinforcement to help establish a
new behavior or strengthen an emerging or
inconsistently performed one
 Develop maintenance program—to be carried out
by patient and caregiver—to ensure optimal
performance of trained skills and/or to generalize use
of skills
 Train patients/caregivers in use of compensatory
skills and strategies (e.g., feeding and swallowing
strategies, cognitive strategies for memory and
executive function)

84
OUTPATIENT SCENARIO: PATIENT CURRENTLY NOT
RECEIVING THERAPY UNDER A THERAPY PLAN OF CARE




Patient with multiple sclerosis needs maintenance program to
slow or prevent deterioration in communication ability caused
by medical condition
Therapy services from qualified SLP may be covered to
establish maintenance program even though patient’s current
medical condition does not yet justify need for individual
skilled therapy sessions
Evaluation, establishment of the program, and training
family or support personnel may require the skills of a
therapist and would be covered
NOTE: In this example, the skills of a therapist are not required
to actually carry out the maintenance program services and, as
a result, are not covered.
85
WHAT IS UNSKILLED CARE?

Unskilled services do not require the special knowledge
and skills of an SLP





Performance reporting without describing modification, feedback,
or caregiver training that was provided during session
Repeating the same activities as in previous sessions without
noting modifications or observations
Activities without rationale or connecting the tasks to goals
Observing caregivers without providing education or feedback
and/or without modifying plan
Recording observations of beneficiary without providing any
direct treatment strategies
86
WHAT IS UNSKILLED CARE?
Service can be self-administered
 Service may be furnished safely and effectively by an
unskilled person without direct or general supervision
 Service is related to activities for the general good and
welfare of patient (e.g., fitness, flexibility, motivation,
diversion)
 Therapist provides an important, yet nonskilled service
in the absence or unavailability of a competent person
 Service is NOT considered a skilled therapy service
merely because the activity is provided by a qualified
therapist

Ref: Pub 100-02 Medicare Benefit Policy, Transmittal 179
87
MEDICARE RULE - USE OF SLP ASSISTANTS
Services of SLP Assistants NOT recognized for Medicare
coverage
 Therapy services provided by SLP Assistants, even if
they are licensed to provide services in their states, will
be considered unskilled services and denied as not
reasonable and necessary
 Check state law for what assistants can and cannot do
in what settings (e.g., schools vs. health care)


Ref: Medicare Benefit Policy Manual, Ch15, 230.3 - Practice of SpeechLanguage Pathology, (Rev. 106, Issued: 04-24-09, Effective: 07-01-09,
Implementation: 07-06-09)
88
MEDICARE RULE - USE OF SLP STUDENTS

Medicare requires 100% personal supervision of SLP students
by qualified SLP in outpatient setting
Must be in the room directing the service
 Must not be engaged in other activities



Student considered extension of qualified practitioner
Qualified* SLP (for Medicare) meets one of the following
requirements:
The education and experience requirements for Certificate of Clinical
Competence in SLP granted by ASHA; or
 Meets educational requirements for certification and is in process of
accumulating the supervised experience required for certification.


Only services of qualified practitioner can be billed and paid
This does NOT apply to non-Medicare settings unless specified

*qualified not always same definition for Medicaid

89
DOCUMENTATION
90
How do you document to show
skilled services?
DOCUMENTATION
 SMART





goals
Specific
Measurable
Actionable/Attainable
Relevant/ Realistic
Time-bound
 Focus
on practical function
 Treatment notes and Progress Reports need to be
patient/client-specific and relevant
Ref for history of SMART goals: Doran, George T. “There’s a S.M.A.R.T. way
to write management’s goals and objectives.” Management Review
70.11 (Nov. 1981): 35.Business Source Corporate. EBSCO . 15 Oct. 2008.
91
DOCUMENTATION - FUNCTIONAL GOAL WRITING

Long Term Goals – Developed for entire episode of care



Short Term Goals – Developed for week or month of
therapy



Measureable and specific to the identified functional
impairment
When episode is anticipated to be longer than one certification
period (90 days), LTG may be specific to current certification
period
Help to track progress toward LTG for episode of care
The “what” and “why”
Treatment Objectives


Treatment strategies and activities
The “how”
92
DOCUMENTATION - REFLECT THE VALUE OF SLP CARE
Descriptions and rationale of skilled treatment
intervention strategies
 Changes made to treatment due to assessment of
patient’s needs on a particular treatment day
 Modification of treatment tasks and rationale due to
patient’s progress or regression
 Reasons for lack of progress and the justification for
continued treatment if treatment continues after
regression or plateau

93
DOCUMENTATION – WHAT NOT TO WRITE
Vague or subjective descriptions of the patient’s care
 Terminology that would not adequately describe the
need for skilled care:

Continue with POC
 Patient tolerated treatment well
 Patient remains stable


Such phraseology does not provide a clear picture of
the results of treatment, nor “next steps” that are
planned.
94
IF IT WAS NOT DOCUMENTED,
IT WAS NOT DONE!
Documentation serves as the means by
which a provider may establish and a
Medicare contractor or auditor may
confirm that skilled care is, in fact, needed
and received
95
RESOURCES
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R1
79BP.pdf
 www.cms.gov/Medicare/Medicare-Fee-forService-Payment/SNFPPS/Downloads/JimmoFactSheet.pdf

96
ASHA RESOURCES
SKILLED VERSUS UNSKILLED TREATMENT
 “Documentation of Skilled Versus Unskilled Care
for Medicare Beneficiaries”

http://www.asha.org/Practice/reimburseme
nt/medicare/Documentation-of-Skilled-VersusUnskilled-Care-for-Medicare-Beneficiaries/
 “Examples of Documentation of Skilled and
Unskilled Care for Medicare Beneficiaries”

http://www.asha.org/Practice/reimburseme
nt/medicare/Examples-of-Documentation-ofSkilled-and-Unskilled-Care-for-MedicareBeneficiaries/
97
2014
CAPCSD ANNUAL MEETING
98
THANK YOU VERY MUCH!
After Lunch – Part Two: Reimbursement
Update with Dr. Bob Fifer
99

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