coding and reimbursement update 2010 · 3-, 4-, and 5-digit codes indicating levels of specificity...

Nancy B. Swigert is the director of speech-language pathology and respiratory care at Central Baptist Hospital, an acute care facility in Lexington, KY. Prior to this, for twenty six years, Nancy was the President of Swigert & Associates, Inc., a private practice providing

speech-language pathology services in the Central Kentucky area. She has written numerous articles and chapters on coding, documentation, billing, and outcomes. She serves on the Editorial Board for Eli Rehab Report. She received her Master’s degree from the University of Tennessee-Knoxville. She is a former president of the Kentucky Speech-Language-Hearing Association, the Council of State Association Presidents, and was president of the American Speech-Language-Hearing Association in 1998. She currently chairs the Health Care Economics Committee and serves on the American Speech-Language-Hearing Foundation Board of Trustees. Nancy B. Swigert, MA, CCC-SLP, BRS-S Director, Speech-Language Pathology & Respiratory Care Central Baptist Hospital, Lexington, KY E-mail: [email protected]

Major changes in how speech-language pathology codes are valued occurred during the past year. The impact of those changes is addressed in this program, which reviews diagnostic and procedural coding systems. Explore such issues as which procedure codes can be used with which diagnostic codes; whether certain diagnostic codes are covered at all, and why; how procedure codes relate to fees paid; when you can (and cannot) negotiate rates; and more.

Learning Outcomes You will be able to: • describe differences in the two major coding systems • list changes in the process for valuing SLP codes and their impact on reimbursement • list typically used CPT codes • discuss edits placed by third party payers on use of certain codes • select appropriate diagnostic and procedure codes for example scenarios

Coding and Reimbursement Update 2010

Faculty

The seminar lasts two hours and

begins at:3:00 p.m. Eastern2:00 p.m. Central

1:00 p.m. Mountain12:00 noon Pacific

Live broadcast Wednesday, December 2, 2009

3–5 p.m. Eastern time

Replay available through December 2, 2010

ModeratorAmy Hasselkus, MA, CCC-SLPAssociate Director, Health Care Services in Speech-Language Pathology, ASHA

ManagerMichele Lash, Instructional Designer, ASHA

This course is offered for 0.2 ASHA CEUs (Intermediate level, Related area).


ASHA Web/Telephone Seminar 0916 1

1

Coding andReimbursementUpdate 2010

Nancy B. Swigert, MA, CCC-SLP, BRS-SDirector, Speech-Language Pathology & Respiratory CareCentral Baptist HospitalLexington, [email protected]

Goals of the session

� Diagnostic Coding System – ICD 9 & 10� Procedural Coding System – CPT

�Typically used codes�Using E&M codes

� Understanding edits� Coding clinic

2



3

Two Coding Systems

� Diagnostic�ICD-9 CM

� Procedural�CPT

4

International Classification ofDiseases – 9th Edition - ClinicalModification (ICD-9-CM)



5

International Classification of Diseases – 9thEdition - Clinical Modification (ICD-9-CM)

� Official classification system used in U.S. toassign diagnostic codes to diseases anddisorders based primarily on body system

� Under auspices of U.S. Dept of Health &Human Services� regulated by agovernmental agency

6

ICD-9 CM

� Government evaluates utilization patternsand appropriateness of health care costs

� Developed approximately 30 years ago� Contains more than 15,000 codes



7

International Classification of Diseases – 9thEdition - Clinical Modification (ICD-9-CM)

� ICD-9-CM published in 3 volumes� Vol. 1 (Tabular List) – Diseases and injuries (001-

999)� Vol. 2 (Alphabetic Index) – diseases, conditions,

and diagnostic terms� Vol. 3 Procedures (hospital inpatient procedures

only)

� Diagnosis/disease coding primarily bybody system

� 3-, 4-, and 5-digit codes indicatinglevels of specificity

8

International Classification of Diseases(ICD-9-CM) – Principles of Coding

� General rule - code to highest degreeofmedical certainty� Carry code to 5th digit when possible (e.g.

784.41 Aphonia, loss of voice� Use most specific code possible



9

ICD-9

�Avoid NOS (not otherwise specified)and NEC (not elsewhere classified)�NOS implies that condition was notadequately described by the provider

�NEC implies that no appropriate codewas found in the tabular list based oninformation provided

10

International Classification of Diseases (ICD-9-CM) – Principles of Coding

�Primary Diagnosis�Condition chiefly responsible for visit�Disease, condition, problem, symptom,

injury, or reason for encounter�If multiple problems exist, select most

resource intensive diagnosis and list othersas secondary

�Secondary diagnoses�Co-existing conditions, symptoms, or

reasons OR�Symptoms found after study



11

Dysphagia Diagnoses� 787.20 Dysphagia, unspecified

� 787.21 Oral Phase� Impaired structure/physiology of palate, tongue, lips, cheeks

� 787.22 Oropharyngeal Phase� Impaired structure/physiology of tongue base and pharyngeal walls

� 787.23 Pharyngeal Phase� Impaired structure/physiology of pharynx and larynx

� 787.24 Pharyngoesophageal Phase� Impaired structure/physiology of upper esophageal sphincter

� 787.29 Other dysphagia

� Some FIs (soon to be MACs) require a secondarydiagnosis� Consult the list in the LCD

12

ICD-9 Diagnostic Coding

� If results of diagnostic testing are NORMAL,code signs or symptoms to report the reason fortest/procedure and explain normal result inreport



13

International Classification ofDiseases (ICD-9-CM) – Principles ofCoding

�Non-physicians (SLPs and AUDs)may code signs, symptoms, or ill-defined conditions

�Disease codes should matchprocedure codes

14

What Were We Thinking?!�Examples of ICD codes billed with speech-

language treatment procedure:

�216 episodes - “stress incontinence male”�202 episodes - “traumatic amputation of

legs”�164 episodes - “malignant neoplasm of

prostate”



15

International Classification of Diseases(ICD-9-CM) – Principles of Coding

DO NOT…� …code conditions previously treated

that no longer exist

� …code “probable,” “suspected,”“questionable,” or “rule out” diagnoses

� …choose a code just to getreimbursed or for your patient’sconvenience…FRAUD

16

V Codes

� Supplementary Classification of FactorsInfluencing Health Status and Contact withHealth Services�Person not currently sick encounters health

services for some specific purpose�Circumstance or problem is present which

influences person’s health status but is not initself a current illness or injury



17

V Codes

� V 57.3 Speech Therapy� Private health plans appear to ignore V

codes as diagnoses, so do not use unlessthe plan requires it.�Description has been changed to Speech-

language therapy

18

New ICD-9 Codes October ’09784.4 Voice & Resonance Disorders

� 784.40 Voice & resonance disorder, unspecified(revised)

� 784.41 Aphonia, Loss of voice� 784.42 Dysphonia Hoarseness (new code)� 784.43 Hypernasality (new code)� 784.44 Hyponasality (new code)� 784.49 Other voice and resonance disorders

(revised)



19

The 784.5 Series Expanded

� 784.5 Other speech disturbanceExcludes: speech disorder due to late effect of CVA (438.10-438.19)

�784.51 Dysarthria (new code)(Excludes: dysarthria due to late effect CVA (438.13)

� 784.59 Other speech disturbance (new code)�Dysphasia, Slurred speech, speech

disturbance NOS

20

Two New Codes: Late EffectsCVA� Circulatory System Chapter� 438.1 Speech and language deficits

�438.11 Aphasia�438.12 Dysphasia�483.13 Dysarthria (NEW CODE)�438.14 Fluency (NEW CODE)



21

Changes May Be Coming…ICD-10-CM� U.S. Dept of Health & Human Services proposing

October 1, 2011, as the compliance date for ICD–10–CM and ICD–10–PCS code sets for all coveredentities.

� Rest of industrialized nations except Italy have beenusing ICD-10 past 10 years (U.S. only using formortality statistics)

22

ICD-10

� ICD-10 code sets contain more than 150,000codes and provides increased granularity

� Can accommodate many new diagnoses andprocedures



23

ICD-10-CM

However…

� Met with opposition by different medical andhealth care groups

� Cost is “burdensome” to providers

� Time consuming to change over and will take“valuable time” from pts

� Asking to wait until after HIPAA upgrades aredone (5 or 6 years)

24

ICD-10-CM – will incorporatechanges made to ICD-9

�R1310 Dysphagia, unspecified�R1311 …, oral phase�R1312 …, oropharyngeal phase�R1313 …, pharyngeal phase�R1314 …, pharyngoesophageal phase�R1319 Other dysphagia� In ICD-9-CM: 787.20 – 787.29



25

Just a sample…ICD-10 for Vocal Pathology

� J38.0 Paralysis of vocal cordsand larynx� Laryngopliega� Paralysis of glottis

� J38.00 Paralysis of vocal cordsand larynx, unspecified

� J38.01 Paralysis of vocal cordsand larynx, unilateral

� J38.02 Paralysis of vocal cordsand larynx, bilateral

� J38.1 Polyp of vocal cord andlarynx� Excludes1: adenomatous polyps

(D14.1)� J38.2 Nodules of vocal cords

� Chorditis(fibrinous)(nodosa)(tuberosa)

� Singer's nodes� Teacher's nodes

� J38.3 Other diseases of vocalcords� Abscess of vocal cords� Cellulitis of vocal cords� Granuloma of vocal cords� Leukokeratosis of vocal cords� Leukoplakia of vocal cords

� J38.4 Edema of larynx� Edema (of) glottis� Subglottic edema� Supraglottic edema

� J38.6 Stenosis of larynx� J38.7 Other diseases of larynx

� Abscess of larynx� Cellulitis of larynx� Disease of larynx NOS� Necrosis of larynx� Pachydermia of larynx� Perichondritis of larynx� Ulcer of larynx

26

International Classification of Diseases9th Revision-Clinical Modification

ICD home page:http://www.cdc.gov/nchs/icd.htm



27

From diagnostic coding toprocedure coding� Diagnostic codes describe the reason you

saw the patient� Procedure codes describe what you did for

the patient

28

2009 CPTCurrent Procedural Terminology,Fourth Edition

“…a set of codes, descriptions, and guidelinesintended to describe procedures and servicesperformed by physicians and other health careprocedures. Each procedure or service isidentified with a five-digit code. The use of CPTcodes simplifies the reporting of services.”



29

Value of CPT codes

� The AMA owns the process of establishingand valuing codes

� CMS assigns actual $$ amount� Medicare Physician Fee Schedule

�Available on ASHA Web site

30

Medicare RBRVS� Medicare implemented the Resource-Based

Relative Value Scale (RBRVS) on January 1,1992

� Standardized physician payment schedulewhere payments for services are determinedby the resource costs needed to providethem

� Most public and private payers utilize theMedicare RBRVS



31

Medicare RBRVS

The cost of providing each service isdivided into three components

1. Physician Work2. Practice Expense3. Professional Liability Insurance

32

Physician Work

Determined by:�The time it takes to perform the service�The technical skill and physical effort�The required mental effort and judgment�Stress due to the potential risk to the

patient



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Practice Expense

�Direct Practice Expense Inputs (RUCReviewed)�Clinical Labor – Non Physician Staff Time (RN,

LPN, MA, Trained Technicians)�Medical Supplies Typically Used to Perform

Procedure�Medical Equipment (Exam Table, Suction

Machine, Defibrillator, Treadmill, etc.)�Indirect Practice Expense (CMS determinedthrough national survey data)�Overhead Costs, Administrative Staff Salaries,

and other Expenses

34

Professional Liability Insurance

� In 2000, CMS implemented the resource-based professional liability insurance (PLI)relative value units

� Based on malpractice insurance premiumdata collected from commercial andphysician-owned insurers from all thestates, the District of Columbia, andPuerto Rico



35

Medicare RBRVS

� Payments are calculated bymultiplying the combined costs of aservices by a conversion factor (amonetary amount that is determinedby the Centers for Medicare andMedicaid Services)

� Payments are also adjusted forgeographical differences in resourcecosts (geographic practice cost index[GPCI])

36

What did MIPPA do to SLPcode values?� CMS and AMA RUC agreed that SLP

codes could now be valued forprofessional work



37

Timeline for Presenting SLP Procedures for Review(2008-2009)

CPTCode

Descriptor PhysicianWork

RUC Meeting Dateto Present

92610 Evaluation of oral andpharyngeal swallowingfunction

No Jan/Feb 2009

92611 Motion fluoroscopicevaluation of swallowingfunction by cine or videorecording

No Jan/Feb 2009

92526 Treatment of swallowingdysfunction and/or oralfunction for feeding

Yes Jan/Feb 2009

92597 Evaluation for useand/or fitting of voiceprosthetic device tosupplement oral speech

Yes Jan/Feb 2009

38

Timeline for Presenting SLP Procedures for Review (2009)

CPTCode

Descriptor MDwork?

RUC MeetingDate to Present

92605 Evaluation for prescription for non-speechgenerating AAC devices

No Oct 2009

92606 Therapeutic services for use of non-speechgenerating devices, including programming andmodification

No Oct 2009

92607 Evaluation for prescription of speech-generatingAAC device, first hour

No Oct 2009

92608 Evaluation [92607], each additional 30 minutes No Oct 200992609 Therapeutic services for use of speech-

generating device, including programming andmodification

No Oct 2009

96105 Assessment of aphasia (includes assessment ofexpressive and receptive speech and languagefunction, language comprehension, speechproduction ability, reading, spelling, writing, e.g.,by Boston Diagnostic Aphasia Examination) withinterpretation and report, per hour

No Oct 2009



39

Timeline for Presenting SLP Procedures for Review (2010)

CPTCode

Descriptor PhysicianWork

RUC MeetingDate toPresent

92506 Evaluation of speech, language,voice, communication, auditoryprocessing, and/or auralrehabilitation status

Yes Feb 2010

92507 Treatment of speech, language,voice, communication, and/orauditory processing disorder(includes aural rehabilitation);individual

Yes Feb 2010

92508 Group, two or more individuals Yes Feb 2010

40

Timed and un-timed CPT codes

� Most codes used by SLPs are not timed� Do not treat these codes as if they are

timed�Don’t bill 92507 x2 because you were with the

patient an hour



41

There are a few timed codes

� A few assessment codes are per hour, includinginterpretation and report

� 15 minute codes – minimum face-to-facetreatment:� 1 unit = 8 to <23 minutes� 2 units = 23 to < 38 minutes� 3 units = 38 to < 53 minutes� 4 units = 53 to < 68 minutes� 5 units = 68 to < 83 minutes� 6 units = 83 to < 98 minutes

� These are reflected in BOLD and underlined onsubsequent slides

42

What are commonly used CPTcodes?

� Let’s look at procedure codes commonlyused by SLP

� Notes I’m sharing are included inAppendix - Medicare CPT Coding Rules



43

Swallowing FunctionCPT codes

�

�

�

�

�

44

Speech & Language EvaluationCPT codes

�

�

�

�

�



45

Speech & Language EvaluationCPT codes

�

�

�

’

46

Voice & ResonanceCPT codes

�

�

�

�

�

�



47

CMS “Therapy Codes”

� Found in Medicare Claims ProcessingManual

� Chapter 5� Section 20.B� List of codes considered therapy codes

48

Speech & Language TreatmentCPT Codes�

�

�

�



49

Group or Concurrent Therapy?

� CMS has stated you can’t bill for individualtherapy (and get a higher rate) forsessions in which therapists treat morethan one patient

� Group therapy for Part A – limits grouptreatment to 25% of any patient’streatment per week/per discipline

� Maximum 4 patients per group

50

Group Therapy

� Services provided simultaneously to two ormore individuals by a practitioner

� Same services provided to everyone� Patients perform same or similar activities� Therapist must be in constant attendance,

but one-on-one patient contact notrequired



Concurrent Therapy

� New regulations and payment revisions forSNFs October 1, 2010

� Concurrent therapy minutes defined as:“treating multiple patients at the same time

while the patients are performing differentactivities.”

51

Concurrent Therapy: Old Rules

� Allowed concurrent therapy in SNFs withno restrictions on number of patientstreated simultaneously or total number ofminutes of treatment time recorded foreach patient

52



Concurrent Therapy: New RulesFall 2010� Limit to two patients at a time� Total number of minutes for the session must be

allocated between the patients� number for each patient cannot be greater than the

total time spent with the patient

53

54

Augmentative and Alternative CommunicationCPT Codes

�

�

�



55

Augmentative and Alternative CommunicationCPT Codes

�

�

�

56

Physical Medicine (97000)CPT codes

�

�



57

Physical Medicine Codes

� CMS has made it clear that SLPs are NOTto use the PM codes�97110 Therapeutic procedure�97112 Neuromuscular reeducation�97530 Therapeutic Activity�97535 Self care

58

� CMS staff says the codes were developedfor PT/OT services based on the vignettes.Exceptions: 97532 & 97533

� CMS has described the speech-languageand swallowing therapy codes as“umbrella” codes for any treatment underthe plan of care.

Limitations to Use of Physical MedicineCodes (97000)



59

� The Highmark intermediary has physicalmedicine codes (in addition to 97532/97533) inits speech-language LCD, effective October2007

� Highmark is the only intermediary that includesphysical medicine codes for speech-languagepathology services

Physical Medicine Codes (cont.)

60

Highmark, cont.� 97110 – Therapeutic exercises to develop

strength/endurance, range of motion andflexibility, each 15 minutes

� 97530 – Dynamic activities to improve functionalperformance, each 15 minutes

� 97535 – Self-care/home management training,each 15 minutes

Physical Medicine Codes (cont.)



61

Evaluation and Management(E/M) Codes

�E/M codes are used to reportevaluation and management servicesprovided as:

�Office visits�Hospital visits�Consultations�Home services�Case management services

62


�E/M codes are classified into newversus established patients

� Further classified into levels relating to�skill, effort, time, and responsibility, using

designations such as “expanded”, “detailed”,and “comprehensive” that require varyinglevels of medical decision making (low,moderate, or high complexity).

� Most are “face to face” encounters



63


Q. Can ASHA members use E/M codes?A. Possibly.

�AMA CPT Code Book refers to E/M codesas physician services

� However, the code book states “Any procedure orservice in any section of this book may be used todesignate the services rendered by any qualifiedphysician or other qualified healthcareprofessional.”

64


Q. Are any speech-languagepathologists of audiologistssuccessfully reporting services usingE/M codes?

A. Yes. It is important to report all services rendered.However, you need to communicate with themanaged care organization and check to see if theE/M codes can be used. Get approval in writing.



65

Examples of E/M Codes

� 99202: Used with 92506 (Speech-LanguageEvaluation) or Audiological Evaluation

� Office visit for new patient involving history-taking,examination, and “straightforward” medical decisionmaking, and lasting 20 minutes face to face with patientand/or family

� Also includes counseling and/or coordination of care withother providers or agencies, consistent with the nature ofthe problem(s) and the patient’s and/or family’s needs

� Some use 99203 which reflects medical decisionmaking of low complexity with 30 minutes face to face

66

More E/M Examples� 99358

Used with 92506 (Speech-Language Evaluation) orAudiological Evaluation

� Prolonged evaluation and management service withoutdirect (face-to-face) patient contact

� Includes review of extensive records and tests,communication with other professionals, and/or thepatient/family; first hour

� 99359 for each additional 30 minutes



67

More E/M Examples� 99211: Used with 92507 (Speech

Treatment)� For the evaluation and management of an established

patient, that may not require the presence of aphysician

� Usually the presenting problem(s) are minimal� Typically 5 minutes are spent performing or

supervising these services

68

E/M Summary� Purchase current AMA CPT Code Book

� Study CPT codes (check ASHA reimbursement site)

� Check with your health plan to obtain written approvalfor use of codes

� Be sure your documentation supports all activities andprocedures performed: “If it isn’t written, it didn’thappen.”



HCPCS – “Hick-Picks”

� Health Care Common Procedure Coding System thatcomplements CPT; maintained by CMS in the publicdomain

� Codes are alphanumeric, beginning with letter followedby 4 digits

� HCPCS Level I codes are procedural codes.� Level II codes identify products, supplies, equipment,

devices and services not included in CPT (e.g., DME,prosthetics, ambulance services)

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HCPCS

� Examples of SLP/A codes included inHCPCS

� Speech generating devices� Voice amplifiers� Repair of AAC systems

� CMS requires HCPCS codes on claims forcovered supplies and devices

� www.cms.hhs.gov/medicare/hcpcs

70



Coding Clarifications (Appendix B)

� Correct Coding Initiative (CCI):�Mutually exclusive�Col 1 & Col 2 (used to be called

comprehensive/component)� Coding Modifiers� Sequential and Simultaneous Treatments

71

72

What about edits?

� CCI (Really NCCI)� National Correct Coding

Initiative� Applies to any Part B

services not rendered ina hospital

� Carriers implement CCIedits

� Intermediaries apply CCIedits to Part B services ininstitutions other thanhospitals

� OCE� This edit applies to

hospital settings� Almost always same as

CCI (except for someservices unrelated torehab)

� Effective 3 months afterCCI effective date



Modifiers

� 59 Distinct Procedural Service-theonly modifier used with editsFor two procedures not ordinarily performed onthe same day by the same practitioner, butwhich, under certain circumstances, may beappropriate to perform and therefore code onthe same day (e.g., different site or organsystem…)

73

Other modifiers

� 76 Repeat Procedures by SamePractitionerWhen a procedure or service is repeated by thesame practitioner subsequent to the originalprocedure…

*22 – when procedure is longer than typical*52 – when procedure is shorter than usual

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Questions and Answers

75

76

Coding and Billing

� If billing Medicare, use CMS 1500�Appendix C

� If billing private insurance, can use CMS1500 or another form�ASHA’s Superbill

� Appendix D



Principles of Coding & Billing

� First step to accurate coding and billing isappropriate service delivery (the rightservices, in the right setting, for the rightamount of time to persons who can benefitin practical “functional” terms)

� Second step is accurate and completedocumentation

77

Diagnosis Coding

Outpatient Treatment: List Diagnosis or problemfor which patient is being treated (e.g., “lateeffects of CVA, aphasia – 438.11”)

Diagnostic Services Only: First code Diagnosis,condition, problem, or other reason forencounterList other Dx (e.g., chronic conditions), second

78



Correct Diagnostic Coding

� If the results of Diagnostic testing are normal,code the signs or symptoms to report the reasonfor the test/procedure (see Sections 780-799 ofthe ICD manual), and explain the normal resultin the practitioner’s report

� Use only current version of ICD manual; useboth Alphabetic Index and Tabular List to code(Alpha first)

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Correct Diagnostic Coding

� Also code signs/symptoms when a definitiveDiagnosis has not been established

� Do not report “rule-out” or suspected Diagnosis

� Be sure to use the ICD-9-CM Official Guidelinesfor Coding & Reporting as a companion tool

80



Procedure Coding

� Use the CPT code that specifically describes theservice delivered.�Do not choose a code that “will get paid” if that code

does not represent the actual service

� Not every code listed in the manual is covered orpayable� Some codes carry certain restrictions (e.g. site;

supervision; time; face-to-face with patient vs.documentation time)

81

Analyzing your code use

� Look at the codes youhave been using

� Know the rate ofreimbursement foreach code

� If either of two codesadequately describeswhat you do…

82



Billing Compliance

� Code and bill for services performed by eligiblepractitioners for eligible patients

� Charge codes, procedure codes, servicedelivered, and documentation must besupported

� No documentation = no billing� Inadequate/incomplete documentation may

mean claims denials upon medical review

83

84

Recovery Audit Contractors-RACs� Demonstration program using Recovery Audit

Contractors (RACs) to detect and correctimproper payments in the Medicare FFSprogram

� The Recovery Audit Contractor (RAC)demonstration program was designed todetermine whether the use of RACs will be acost-effective means of adding resources toensure correct payments are being made toproviders and suppliers and, therefore, protectthe Medicare Trust Fund



85

RACs

� Demonstration programs finishing in 2009�CA, FL, NY

� Full contracts for RACs in all 50 states by2010

� Best prevention is documentation thatshows medical necessity and dates thatactual procedures performed

86

Feedback from RACsNational Medicare Recovery Audit Contractor Summit, March 2009

� RACs will focus on:�Payments made for services that don’t meet

Medicare medical necessity requirements�Payments made for services that wereincorrectly coded

�Services highlighted by the OIG and GAO�Known high-risk DRGs



87

Feedback from RACsNational Medicare Recovery Audit Contractor Summit, March 2009

� RACs have coders related to eachspecialty

� They will data-mine, looking for codingerrors

88

Feedback from Health CareProvidersNational Medicare Recovery Audit Contractor Summit, March 2009

� Critical to success with RAC audits:�Conduct proactive assessments�Review your documentation extensively� Educate your staff� Prepare adequately for appeals� Appeal everything, if you are prepared�Use data mining to improve outcomes�Use RAC tracking software to manage audits and

appeals� Spreadsheets, share drives, and e-mail will fail in long run



89

Feedback from Health CareProvidersNational Medicare Recovery Audit Contractor Summit, March 2009

� Meeting deadlines is a MUST� If you miss a record request or appeal deadline by

only one day, RAC will recoup disputed revenues andcash flow will be impacted immediately

� During demo period, success rates with appealsconsistently low (less than 10% average) in first2 levels of appeal� At 3rd level, success rates improved significantly

90

Coding Clinic

� Let’s practice selecting diagnostic andprocedural codes



91

Bedside eval normal, suspectpharyngeal� Bedside/clinical evaluation completed and there

are no signs/symptoms of oral or pharyngealdysphagia

� However, patient’s pulmonary status iscompromised and has history of pneumonia

� You want to refer for instrumental study� ICD: 787.20 Dysphagia unspecified� CPT: 92610

92

Bedside reveals oral problems

� Bedside/clinical evaluation revealedsignificant oral dysphagia: pocketing,increased time for bolus prep but no signsof pharyngeal dysphagia

� ICD Code: 787.21 Oral phase� CPT Code: 92610



93

Results of MBS

� Videofluoroscopic evaluation revealsdifficulty with preparation of the bolus,premature loss over back of tongue, somepenetration into upper laryngeal vestibuleand residue in pyriforms with risk ofaspiration

� ICD Code: 787.22 Oropharyngeal� CPT Code: 92611

94

Scenario: Voice therapy

� Patient seen for voice therapy� Relaxation exercises for jaw, neck, shoulders� Digital manipulation of the larynx� Vocal function exercises performed� Discussed with patient avoiding high noise

situations when talking and encouraged her toproblem solve such situations



95

What is the CPT code? Thechoices are:� 97530 – Therapeutic activities, direct patient

contact by the provider (use of dynamic activitiesto improve functional performance) each 15minutes

� 97532 – Development of cognitive skills toimprove attention, memory, problem solving(includes compensatory training)

� 92507 – Treatment of speech, language, voice,communication, and/or auditory processingdisorder; individual

96

The answer is…

� 92507 CPT�Treatment of speech, language, voice,

communication, and/or auditory processingdisorder; individual



97

Scenario: Speech evaluationand treatment same day� SLP performs speech/language evaluation and

treatment on the same date of service.� CPT Code(s): 92506

92507� No modifier needed� Would need to have Plan of Care by next day for

Medicare� For private insurance, would depend on whether

separate authorization needed for treatment

98

Scenario: Voice evaluation

� Patient seen for voice evaluation� Clinical exam included detailed case history,

interview re: typical voice use and contributingfactors

� More specific measurements are obtained usinginstrumentation (not defined)� VisiPitch� Videostroboscopy� KayPentax CSL



99

What CPT codes do you use?

� 92506 for the clinical part of the exam� SLP in private practice can’t bill Medicare:

�92520 for the aerodynamic and acoustictesting obtained through instrumentation� Add modifier –59 to show distinct procedure� Add –52 if you performed only a single test

�This code is not on the “always therapy” list

100

Scenario:Laryngeal Videostroboscopy� 10-year-old patient is referred by ENT doc for a

voice evaluation and laryngeal videostroboscopy� Referring ICD-9-CM codes are:

� 784.42 Dysphonia, Hoarseness� 478.4 Nodules

� Your clinical evaluation indicates normal vocalquality



101

You can do the voice evaluation

� Code 92506 for Voice Evaluation� Stroboscopy 31579 – may be possible to

bill to private insurance� Videostroboscopy cannot be billed to

Medicare by independent SLP because itis not on the “always therapy” list�In fact, it’s considered a surgery code

102

What diagnostic code(s) can you include inyour final report? Your choices are:

� 784.42 and 478.4 with an explanation anddescription of findings in the written report

� OR

� You do not need a code since you do notbill the patient/client when the findings arenormal



103

The answer is:

� 784.42 and 478.4 with an explanation anddescription of findings in the written report

� Code for what the patient was referred toevaluate

104

Scenario: Pediatric ArticulationEvaluation� 6-year-old child referred for articulation eval�Medical history is negative for any known

neurological or congenital conditions relatedto the child’s speech production

�Clinical evaluation suggests that child’s oral-motor and articulation behaviors are indicativeof apraxia

What diagnostic code (ICD) do you use?



105

The answer is…

� 315.39 Other (Developmental speech orlanguage disorder)�Developmental articulation disorder�Dyslalia�Phonological disorder

� 784.69 Apraxia

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Co-Treatment

� 4-year-old with verbal apraxia andimpaired sensory processing and finemotor control

� The child spends 60 minutes in a sessionwith the OT and the SLP

� What should each professional bill?



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Co-Treatment

� Each professional can only bill for theamount of time they spent with the child�30 minutes OT�30 minutes SLP

� NOT 60 minutes by each� SLP tx code is not timed…. That

complicates things!

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Early Dementia? Aphasia?

� Neurologist refers patient withsigns/symptoms of word finding problemsand memory loss

� Neurologist refers for evaluation todetermine if patient is presenting withprimary progressive aphasia vs. dementia



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Evaluation

� You administer Boston Diagnostic AphasiaExamination and Boston Naming� Spend 50 minutes with patient and 20 minutes

analyzing and writing results� You also administer the Ross Information

Processing Test and the Wechsler MemoryScale� Spend 90 minutes with patient and then 35 analyzing

and writing report

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CPT code(s)?

� 92506 Evaluation of speech, language…� 96105 Assessment of Aphasia, per hour� 96125 Standardized Cognitive

Performance Testing, per hour



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Answer:

� 96105 x1� 96125 x2� With careful documentation about the

different types of assessments performed

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Treatment of Dementia

� Your evaluation reveals this is likely earlydementia and not an aphasia

� The neurologist asks you to treat� You develop a plan of care for addressing

memory and organization deficits and familyteaching

� You plan to see the patient for hour longsessions 1x week� Last 15 minutes each session actively involving family

in planning home routine modifications



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� Short term therapy may be appropriate� Which CPT code:

�92507 Speech, language… treatment�97532 Cognitive skills development, each 15

minutes�97535 Self-care/home management training,

each 15 minutes

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� 97532 x3 (45 minutes)� 97535 x1 (15 minutes)

�If permitted by the MAC� If not, could bill 97532 x4



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Mobile MBS

� Area nursing care facilities complain about thedistance and expense to send their patients toan area hospital for videofluoroscopicevaluations

� A radiologist colleague has purchased a mobilevideofluoro unit and wants you to perform thestudies

� Can you?� What code will you use?

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Mobile MBS Services

� Medicare Benefit Policy Manual15/230.3.D.4 states modified bariumswallow studies can be performed withfixed or mobile equipment

� What CPT code is appropriate?� How would you bill Medicare?



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Mobile MBS

� 92611 is the appropriate code� Should be billed with radiology procedure

74230� BUT…consolidated billing at the SNF

requires you to bill the SNF�You’re not bound by the MPFS rate but can

negotiate with the SNF

Lots of resources from ASHA forpurchase, and some for free!

� Medicare Handbook forSpeech-LanguagePathologists

� Medicare Handbook forAudiologists

� Health Care Plan Coding &Claims Guide

� Appealing Health Plan Denials� Negotiating Health CareContracts and CalculatingFees

� Getting Your ServicesCovered: A Guide to WorkingWith Insurance and ManagedCare Plans

NO CHARGE:� 2009 Medicare Fee

Schedule for Speech-Language Pathologists

� 2009 Medicare FeeSchedule and HospitalOutpatient ProspectivePayment System forAudiologists

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Web site Resources

� ASHA’s Billing & Reimbursement Web site� http://www.asha.org/practice/reimbursement/default

� Medicare Fee Schedule (CMS)� http://www.cms.hhs.gov/PhysicianFeeSched/

� ICD-9-CM (NCHS)� http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/

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Medicare Learning Network

http://www.cms.hhs.gov/MLNGenInfo/01_overview.asp



Questions and Answers

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Thank You!

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