CODING, DOCUMENTATION & REIMBURSEMENT FOR SLPS LEARN THE BASICS FROM THE EXPERTS (#1011) ASHA Health Care Economics Committee 2015 ASHA Convention

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1 CODING, DOCUMENTATION & REIMBURSEMENT FOR SLPS LEARN THE BASICS FROM THE EXPERTS (#1011) ASHA Health Care Economics Committee 2015 ASHA Convention 1

2 SPEAKER DISCLOSURES Financial None Non-Financial Solicited Presentation - Health Care Economics Committee (American Speech-Language-Hearing Association) 2

3 HEALTH CARE ECONOMICS COMMITTEE (HCEC) PURPOSE Assist Government Relations and Public Policy Board (GRPP) and cluster staff in determining current economic issues and develop goals for ensuring equitable coverage and reimbursement Develop recommendations for coding (procedural and diagnostic) and relative values of procedural codes Anticipate future socioeconomic needs of the professions and the consumers 3

4 2015 HEALTH CARE ECONOMICS COMMITTEE (HCEC) SLP Members Dee Adams Nikjeh, Co-Chair, SLP RUC Advisor Katie Holterman Renee Kinder Carmen Vega-Barachowitz, SLP alternate RUC Advisor Tim Weise Joan Mele-McCarthy, VP for Government Relations & Public Policy Audiology Members Stuart Trembath, Co-Chair, CPT Advisor Leisha Eiten, AUD RUC Advisor Bob Burkard Bob Fifer Wayne Foster Mike Hefferly ASHA Staff Tim Nanof, Ex Officio, Director, Health Care Policy & Advocacy Neela Swanson, Staff Liaison, Director, Health Care Coding Policy 4

5 AGENDA Key Health Care Coding Systems International Classification of Diseases -10th Rev Principles of ICD Coding Tools and Resources or ICD-10-CM 10th Revision Current Procedural Terminology Coding Tools (Edits & Modifiers) From Procedure to Payment 2016 Medicare Physician Fee Schedule Payment Systems, Work Settings, Coverage Criteria Medicaid Medicare Part A Acute care and Skilled Nursing Facilities Medicare Part B Outpatient care and Coding Scenarios Questions & Answers 5

6 HEALTH CARE CODING SYSTEMS Health Care Common Procedures Coding System (HCPCS) HCPCS Level I Current Procedural Terminology (aka CPT codes) Represent what we DO (procedures & services) with the client/patient Owned by American Medical Association HCPCS Level II Codes used to report supplies, equipment, and devices International Classification of Diseases, 10th Revision, Clinical Modification (aka ICD-10 codes) Diagnostic codes that describe the REASON we are evaluating or treating the client/patient 6

7 PURPOSE OF CODING SYSTEMS Provide common language among providers, third-party payers, and benefits administrators Standardize descriptions of procedures, names of diagnoses, and names of items/supplies Provide data for government to evaluate utilization patterns and appropriateness of health care costs Provide data for health-related research 7

8 MOVED FROM ICD-9-CM TO ICD-10-CM October 1,

9 ICD-10-CM BEGAN OCTOBER 1, 2015 ICD-10 includes approx 160,000 ICD-10-CM diagnosis codes for all settings > 68,000 codes in Clinical Modification ICD-10-PCS procedure codes for hospital inpatients Chapters based on body systems (e.g. nervous, circulatory, respiratory, digestive) 3-7 alphanumeric characters instead of current 3-5 digits Owned by the World Health Organization (WHO) Required for everyone covered by the Health Insurance Portability Accountability Act (HIPPA) Does NOT affect CPT coding 9

10 EXAMPLES OF ICD-10-CM F80. F80.1 F80.8 I J38.2 R13.11 R48.8 R49.0 R49.21 Phonological disorder; Functional speech articulation disorder Expressive language disorder Childhood onset fluency disorder Aphasia following cerebral infarction Nodules of vocal cords Dysphagia, oral phase Other symbolic dysfunctions Dysphonia Hypernasality 10

11 ICD-10 CODING PRINCIPLES Highest degree of medical certainty or specificity Carry out to the 4th or 5th digit when possible For example General R41.8 Other symptoms and signs involving cognitive functions and awareness More specific R Cognitive communication deficit R Frontal lobe and executive function deficit 11

12 PRINCIPLES OF ICD CODING Avoid Not Otherwise Specified (NOS) and Not Elsewhere Classified (NEC) codes Code NOS when the information in the medical record provides detail for which a specific code does not exist R48.9 Other symbolic dysfunctions H91.8X Other specified hearing loss R13.19 Other dysphagia R13.10 Dysphagia, unspecified or Difficulty in swallowing NOS (versus R13.11 Dysphagia, oral phase) Code NEC when a condition is recorded to a level of specificity not identified by a specific code H91.3 Deaf nonspeaking, not elsewhere classified 12

13 ICD CODING PRINCIPLE When results of diagnostic testing are NORMAL, code signs or symptoms to report the reason for test/procedure and explain normal result in report 13

14 OFFICIAL INSTRUCTIONS ON HOW TO CODE WHEN THE RESULTS ARE NORMAL For outpatient services, ICD-10-CM guidelines state, Do not code diagnoses documented as 'probable,' 'suspected,' 'questionable,' 'rule out,' or 'working diagnosis' or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. For inpatient services (including short-term, acute, and longterm care), ICD-10-CM advises "If the diagnosis documented at the time of discharge is qualified as 'probable,' 'suspected,' 'likely,' 'questionable,' 'possible,' or 'still to be ruled out' or other similar terms indicating uncertainty, code the condition as if it existed or was established. ICD-10-CM Official Guidelines for Coding and Reporting 14

15 ICD CODING PRINCIPLE ICD code (reason) and CPT code (procedure) should correspond for encounter. Example: ICD R13.11 Dysphagia, oral phase CPT Clinical Swallow Evaluation 15

16 ICD CODING PRINCIPLE Primary diagnosis - condition (disease, symptom, injury) chiefly responsible for visit or reason for encounter Secondary diagnoses - co-existing conditions or symptoms, or condition found after study Primary R13.10 Dysphagia, unspecified Secondary (after MBS) R13.12 Dysphagia, oropharyngeal phase Exceptions - Instructions for code first, use additional code, or in diseases classified elsewhere I Dysphagia following cerebral infarction use additional code to identify the type of dysphagia, if known R13.1 Dysphagia Code first, if applicable, dysphagia following cerebral vascular disease Procedures may also be specific to your work setting 16

17 ICD CODING PRINCIPLE - NEW Excludes1 Indicates that codes should never be listed together because the two conditions cannot occur together Example: F80.1 Expressive language disorder, developmental dysphasia or aphasia, expressive type Excludes1 mixed receptive-expressive language disorder (F80.2); dysphasia and aphasia NOS (R47.-) 17

18 ICD CODING PRINCIPLE - NEW Excludes 2 Indicates codes that may be listed together because the conditions may occur together, even if they are unrelated Example: G40.80Acquired aphasia with epilepsy [Landau-Kleffner] Excludes2 selective mutism (F94.0) intellectual disabilities (F70-F79) pervasive developmental disorders (F84.-) 18

19 ASHA TOOLS FOR ICD-10-CM Lists for SLP and AUD ICD-10 codes on the ASHA website Online Mapping Tools for ICD-9 to ICD-10 codes: Enter the ICD-9 code and a list of the corresponding ICD-10 codes is generated Mapping Spreadsheet to view related mappings in one list Products are free and tailored for speech-language pathology and audiology 19

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24 ASHA ICD-10 MAPPING TOOL 24

25 CURRENT PROCEDURAL TERMINOLOGY aka CPT codes 25

26 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 26

27 AMA CRITERIA FOR CPT CODES Unique procedure that is not covered by other established codes Procedure widely used within U.S. Not investigational Supported by substantial peer reviewed literature in published in US journals 27

28 RELATIVE VALUE UNIT (RVU) Every CPT procedure or service has a resource-based relative value Payments for services are determined by the resource costs needed to provide them Each code has a relative value based on 3 components: Professional work Practice expense Professional liability insurance All procedures are ranked on this same scale Standardized physician payment schedule 28

29 RELATIVE VALUE UNIT: 3 COMPONENTS *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 29

30 HOW DOES A CPT CODE GET A DOLLAR VALUE? Relative Value Units (RVUs) are assigned thru a rigorous procedure developed by the AMA Recommendations for RVUs sent to Centers for Medicare and Medicaid (CMS) Accepted, rejected, or adjusted Ranked RVU x Monetary Conversion Factor = Medicare Payment per Procedure Establishes the Medicare Physician Fee Schedule Payment adjusted for geographic location 30

31 CPT Process ASHA Complete Request Form Collect Data Write Vignettes Collaborate (AAO HNS) HCPAC CPT Editorial Panel Defend Negotiate Rationalize RUC HCPAC PEAC Practice Expense Advisory Committee Defend Resources RUC Relative Value Update Com. (Recommends a Relative Value) Defend Professional Work Value Practice Expense Professional Liability/Insurance New CPT Book Approximately 2 Years CMS Accept, Reject, Adjust Reimbursement Assigned 31

32 SUSTAINABLE GROWTH RATE REPEALED APRIL 14, 2015 Congress passed the Medicare Access and CHIP Reauthorization Act- repeals the Sustainable Growth Rate (SGR) payment formula that was used to determine the Conversion Factor Conversion Factor will remain stable with annual payment increase of 0.5 percent Began July 1, 2015, continues each subsequent year through 2019 Payment frozen from 2020 to 2025 After 2025 payment adjustments based on participation in alternative payment models 2016 Conversion factor = $ (as compared to $ from 2015) 32

33 2016 MEDICARE PHYSICIAN FEE SCHEDULE 33

34 MEDICARE PHYSICIAN FEE SCHEDULE (MPFS) All references to MPFS include the 80% that Medicare pays and the 20% patient coinsurance Many private insurers and Medicaid programs model their own payments on Medicare s MPFS ends up largely determining physician incomes and ours too MPFS appears in Final Rule in late fall for following year 34

35 SUSTAINABLE GROWTH RATE REPEALED APRIL 14, 2015 Therapy cap and exceptions process will continue for 2 years until December 31, KX modifier, if applicable for those who have exceeded $1,960 cap still in effect Repeal effort part of the Medicare Access and CHIP Reauthorization Act 35

36 MANUAL MEDICAL REVIEW MMR began Oct 2012 for combined SLP/PT services over a $3,700 threshold; separate OT threshold of $3,700 Extended through December 31, 2017 Targeted Claims Reaching $3,700 High denial rates Aberrant or questionable billing activities Newly enrolled provider Therapy provided to treat a certain medical condition Provider is part of a larger group identified (using above criteria) Effective Date?? No later than 90 days after the date of enactment (4/16/2015) However, CMS missed July deadline for confirming the new targeted criteria Have not made any further statements and vague responses to inquirie 36

37 RULES AND TOOLS FOR CPT PROCEDURE CODES Modifiers CCI Edits Timed Codes 37

38 CODING RULES & TOOLS EDITS Two types of similar edit systems depending on setting National Correct Coding Initiative (CCI) any outpatient services not rendered in a hospital Outpatient Code Editor (OCE) outpatient hospital services Automated edit systems used by CMS to control specific CPT code pairs that can be reported on the same day for the same patient CCI is updated quarterly and OCE follows one quarter later Since late 2010, CCI also applies to Medicaid per federal law 38

39 MODIFIERS SLPS NEED TO KNOW RIGHT NOW Indicates Distinct and Separate Procedural Service Only modifier used with NCCI edits for SLP-related codes For two procedures not ordinarily performed on same day by 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) CPT (MBS) & (Clinical Swallow Eval) CPT (Dysphagia tx) & (Cog tx) CPT (Group tx) & (Indiv tx) CPT (Aphasia assessment) & (Cognitive Performance testing) SLPs should continue to use -59 until notified by your payer regarding implementation of new supplemental modifiers for therapy services -52 Indicates Shortened Procedure 39

40 ASHA CCI EDIT PAGE FOR SLP CODES 40

41 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 speech tx dysphagia tx clinical eval of swallowing cognitive performance testing per hour aphasia assessment per hour 41

42 TIMED VERSUS UNTIMED CPT CODES SLP TIMED PROCEDURES 92607: Evaluation for prescription of speech-generating device, first hour 92608: each additional 30 minutes 92626: Evaluation of auditory rehabilitation status, first hour 92627: each additional 15 minutes 96105: Assessment of aphasia, per hour 96125: Standardized cognitive performance testing, per hour 97532: Development of cognitive skills, each 15 minutes 42

43 TIMED VERSUS UNTIMED CPT CODES TIME REQUIREMENTS Time documented must correspond to number of units billed on the claim Time spent must exceed halfway point dictated by the code: 1-hour unit 31 minutes ½ hour unit 16 minutes 15-minute unit 8 minutes Subsequent timed-units may not be counted until the full value (first code) plus ½ of the value is exceeded (second code) 43

44 TIMED VERSUS UNTIMED SLP CODES TIME REQUIREMENTS EXAMPLE An aphasia assessment took 60 minutes with the patient and interpretation and report writing was documented in the record to take 45 minutes. CPT = 1 hour per each unit billed, max of 3 To bill a second unit of 96105, 91 minutes (first hour + ½ of second hour + 1 min) must be documented on evaluation and report. In this case, 105 minutes are documented. It is appropriate to bill 2 units of

45 HEALTH CARE PAYMENT SYSTEMS Medicaid Medicare 45

46 MEDICAID - BASICS Enacted in 1965 as part of Title XIX of the Social Security Act Partnership program funded jointly between the States and Federal Government with more than half funded by the Feds. Mandatory service example is EPSDT. Optional service example is Rehab and other therapies. 46

47 MEDICAID The Affordable Care Act expanded coverage for the poorest Americans by creating an opportunity for states to provide Medicaid eligibility, effective January 1, 2014, for individuals under 65 years of age with incomes up to 133% of federal poverty level Federal law requires states that participate in Medicaid to cover certain population groups (mandatory eligibility groups) and gives them the flexibility to cover other population groups (optional eligibility groups). In all states, Medicaid provides free or low-cost care for some lowincome people, families and children, pregnant women, the elderly, and people with disabilities. States set individual eligibility criteria within federal minimum standards. 47

48 MEDICAID RESOURCES Medicaid uses the same ICD and CPT health care coding systems as Medicare and other payers, but payment policies and rates vary widely from state-to-state. Check with your State Medicaid agency for a fee schedule and provider manuals ASHA Tool Kit: ASHA STAR Network: Advocates in your State 48

49 MEDICAID OR MEDICARE Both are Government sponsored healthcare programs in the US that differ in the way they are governed and funded. Medicaid is an assistance program that covers low and no income families and individuals. Medicare is an insurance program that primarily covers seniors ages 65 and older and disabled individuals who qualify for Social Security Some may be eligible for both depending on their circumstances. 49

50 MEDICARE Parts ABCD Coverage Criteria Payment Systems Documentation Supervision 50

51 ABCS OF MEDICARE 4 TYPES OF COVERAGE Medicare is for 65+ population and for certain severe disabilities A: Everyone 65+ who paid taxes into Medicare has Part A Hospital inpatient services, inpatient psych, Inpatient Rehab Facilities, Skilled Nursing Facilities, Home Health, Hospice B: Not everyone has Part B Outpatient services, durable medical equipment, ambulance service, mental health, clinical research C: Medicare Replacement Plans Medicare Advantage Plan may have different rules, but the plan must give beneficiary at least the same coverage as Original Medicare D: Drug coverage 51

52 MEDICARE PART A Hospital Inpatient 52

53 MEDICARE PART A HOSPITAL INPATIENT MEDICARE COVERAGE CRITERIA Everyone 65+ who paid taxes into Medicare (and spouse) has Part A Hospital Inpatient - defined in statute and regulations as a person formally admitted for bed occupancy with expectation that s/he will at a minimum remain overnight Patient is under care of physician and requires skilled therapy services, as demonstrated by physician s signature on the plan of care (POC) All covered Medicare services must be provided at a level of complexity that requires a qualified professional for safe and effective care 53

54 MEDICARE PART A HOSPITAL INPATIENT PAYMENT SYSTEM All Part A is paid through a Prospective Payment System (PPS) Payment model in which payment is made on a predetermined amount regardless of procedures performed Diagnosis Related Groups (DRGs) all services provided in hospital with exception of specific physician services DRGs determined by: Affected organ system Surgical procedures Co-morbidities and ICD-10 codes Gender HCPCS codes may be used for tracking purposes but are not basis for payment to hospital; Procedures will be tracked by hospital and reported to CMS as resources, but are not actually billed using CPT codes 54

55 MEDICARE PART A ACUTE CARE HOSPITAL INPATIENT DOCUMENTATION Medicare Benefit Policy Manual does not specifically address Part A documentation and refers to outpatient services as the standard Guidance/Guidance/Manuals/downloads/bp102c15.pdf Emergency Department and Observation Patients are covered through Medicare Part B Evaluation Only When evaluation is the only service provided, it serves as the POC Contains a diagnosis and/or a detailed description of the condition for physician to diagnose a condition Referral or order for evaluation serves as the certification that the evaluation was needed 55

56 MEDICARE PART A ACUTE CARE HOSPITAL INPATIENT DOCUMENTATION Plan of Care The focus of Medicare documentation (Individualized, Reasonable, Necessary) Developed before initiation of treatment Includes diagnosis or diagnoses related to the therapy provided Delineates long-term goals Includes functional reporting G-codes for current status and the long-term goals ( not required for Part A but might become Part B and then needed) Specifies type, amount, frequency, and duration of therapy services Must be certified by physician, clinical nurse specialist, nurse practitioner, or physician assistant ASAP within 30 calendar days of the first treatment session Challenge in Acute Care: Patient acuity and LOS. 56

57 MEDICARE PART A ACUTE CARE HOSPITAL INPATIENT DOCUMENTATION Progress Note required by CMS minimally every 10th treatment day Name and credentials of service provider Assessment of progress made toward therapy goals, including objective measurements Treatment plan revisions or modifications Changes to long or short-term goals Functional reporting not required for Part A only Part B Current status of patient, Projected status, G-codes and severity modifiers Method of measuring severity (e.g., National Outcome Measurement System) Discharge Note - follows same requirements as Progress Note 57

58 MEDICARE THREE LEVELS OF SUPERVISION General supervision Requires physician s involvement certification of the plan of care signature on the plan of care demonstrates the physician s involvement Direct supervision requires that physician immediately available while procedure is performed does not require physician to be in room, but must be on premises Personal supervision requires that physician is present in the room during the performance of the procedure 58

59 ASHA STUDENT SUPERVISION The ASHA Code of Ethics, the Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA) and the Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC) concur that the level of student supervision should be based on: The abilities of the student, The complexity of the case, and Ultimately, the client s well being 59

60 MEDICARE PART A HOSPITAL SUPERVISION STUDENTS & UNLICENSED CLINICAL FELLOWS Because of the PPS utilized for inpatient hospital Part A services, claims submitted by hospitals typically list the attending physician as provider of record Assumption - services are provided by appropriately trained auxiliary personnel and physicians are readily available in cases of emergency Thus, Part A Hospital supervision is presumed DIRECT 60

61 MEDICARE PART A Skilled Nursing Facilities 61

62 MEDICARE PART A SKILLED NURSING FACILITIES COVERAGE CRITERIA First requires a three-day qualifying hospital stay All 4 of the following criteria must be met for service coverage: Patient requires skilled nursing services or skilled rehabilitation services (i.e., services that must be performed by or under the supervision of professional or technical personnel) are ordered by a physician and the services are rendered for a condition for which patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services; The patient requires these skilled services on a daily basis; and As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. The services delivered are reasonable and necessary for the treatment of a patient s illness or injury, i.e., are consistent with the nature and severity of the individual s illness or injury, the individual s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity. 62

63 MEDICARE PART A SKILLED NURSING FACILITY PAYMENT SYSTEM Part A for first 100 days in SNF; then, Part B may apply Prospective Payment System (PPS) based on patient case-mix determined by assessment through Minimum Data Set (MDS) PPS based on Resource Utilization Groups (RUGs) est RUG levels for therapy are classified as: Ultra high: at least 720 mins; Min 2 disciplines, one at least 5 days/wk Very high: at least 500 mins; Min 1 discipline 5 days/wk High: at least 325 mins; Min 1 discipline 5 days/wk Medium: at least 150 mins; Min 5 days/wk Low: at least 45 mins; Min 3 days/wk, +2 restorative nursing services 6 days/wk Time spent on evaluation included in calculation of RUG rates Part A payment, CPT codes not required; Facility may use for data 63

64 MEDICARE PART A SKILLED NURSING FACILITY DOCUMENTATION Refer to Medicare Part B Outpatient Documentation (MBPM, Ch 15) for minimum requirements Guidance/Guidance/Manuals/downloads/bp102c15.pdf 64

65 MEDICARE PART A SNFS - DOCUMENTATION WHAT IS SKILLED CARE? Analyze medical/behavioral data and select appropriate evaluation tools/protocols Design plan of care (POC) Develop and deliver treatment activities that follow a hierarchy of complexity to achieve the target skills for a functional goal Based on expert observation, modify activities during treatment sessions to maintain patient motivation and facilitate success. Conduct ongoing assessment of patient response Determine appropriate time for discharge or termination of SLP service Explain rationale and expected results Develop maintenance program to be carried out by patient and caregiver Train patients/caregivers in use of compensatory skills and strategies Unskilled-Care-for-Medicare-Beneficiaries/ 65

66 MEDICARE IMPROVEMENT STANDARD Effective January 1, 2014 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 statute specifies rehabilitative 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 Guidance/Guidance/Transmittals/Downloads/R179BP.pdf 66

67 MEDICARE PART A SNFS - DOCUMENTATION 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 the 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 67

68 MEDICARE PART A SNFS - DOCUMENTATION 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 Ask yourself, Can this be done by someone else? Ref: Pub Medicare Benefit Policy, Transmittal

69 MEDICARE PART A SNF-SERVICE DELIVERY TYPES OF TREATMENT Group Therapy (CPT 92508) One provider, 4 patients performing same activity Supervised by SLP who is not supervising any other individuals Record total number of mins MDS will divide total by 4 for group mins Concurrent Therapy One provider, 2 patients performing different activities Patients must be in line-of-sight of treating SLP for Medicare Part A Part B residents may not be treated concurrently Record total number of mins MDS will divide total by half for concurrent mins Co-treatment Therapy Two providers of different disciplines, 1 patient Each discipline is responsible for independently establishing its own POC Total number of minutes per discipline is counted for Part A residents Part B residents may not be billed separately by therapists for same or different service provided at same time to same patient Source: RAI Version 3.0 Manual CH 3: MDS Items [O], Oct

70 MEDICARE PART A SNFS - SUPERVISION STUDENTS & UNLICENSED CLINICAL FELLOWS Effective October 1, 2011, students are not required to be in the line-of-sight for supervision at the discretion of the supervising provider within individual facilities All state and professional practice guidelines for student supervision must be followed. Students and unlicensed CFs are considered extensions, not independent of, the professional provider Although SNF supervision rules for Part A services are less stringent than Part B rules, responsibility of care remains 100% with supervising provider 70

71 MEDICARE PART A SNFS - SUPERVISION STUDENTS & UNLICENSED CLINICAL FELLOWS Rules of SNF supervision Individual Therapy: Student treats one resident; supervisor does NOT treat a resident or supervise another student. Supervisor provides direct supervision to one student with one resident. Concurrent Therapy: Student treats one resident and supervisor treats another resident. Supervisor provides direct supervision to one student and simultaneously provides treatment to one resident. Group Therapy: Student treats 4 residents simultaneously and supervisor does NOT treat a resident or supervise another student. Supervisor may not provide other treatment or supervise another student at the same time 71

72 MEDICARE PART B OUTPATIENT SERVICES Clinical research Ambulance services Durable medical equipment (DME) Mental health Outpatient therapy services 72

73 MEDICARE PART B OUTPATIENT THERAPY COVERAGE CONDITIONS Individuals residing in the US who become entitled to premium-free Part A are automatically enrolled in Part B Part B is voluntary program Requires payment of a monthly premium Individuals may refuse enrollment and coverage Conditions of coverage for services must be demonstrated in documentation Conditions for therapy services in Code of Federal Regulations (CFR 424): Patient is under care of a physician and requires skilled therapy services, as demonstrated by physician s signature on plan of care. Name and NPI of physician certifying plan of care must be on claim form for therapy services Functional reporting requirements must be on claim and consistent with documented goals and outcomes 73

74 MEDICARE PART B OUTPATIENT THERAPY PAYMENT SYSTEM 2016 Medicare Physician Fee Schedule Fee-for-service 74

75 MEDICARE PART B OUTPATIENT SERVICE DELIVERY TYPES OF TREATMENT Group Therapy CPT Code One provider, 2-4 patients performing the same activity Concurrent Therapy Code for treatment procedure provided to the individual (e.g., CPT 92507, CPT 92526) One provider, 2 patients performing different activities Co-treatment Therapy Two providers of different disciplines, 1 patient Each discipline is responsible for independently establishing its own POC 75

76 MEDICARE PART B OUTPATIENT SERVICES DOCUMENTATION Evaluation When evaluation is the only service provided, it serves as the POC Contains a diagnosis and/or a detailed description of the condition for physician to diagnose a condition Referral or order for evaluation serves as the certification that the evaluation was needed Guidance/Guidance/Manuals/downloads/bp102c 15.pdf 76

77 MEDICARE PART B OUTPATIENT SERVICES DOCUMENTATION Plan of Care The focus of Medicare documentation (Individualized, Reasonable, Necessary) Developed before initiation of treatment Includes the diagnosis or diagnoses related to the therapy provided Delineates long-term goals Includes functional reporting G-codes for the current status and longterm goals Specifies type, amount, frequency, and duration of therapy services POC must be certified by a physician, clinical nurse specialist, nurse practitioner, or physician assistant as soon as possible within 30 calendar days of the first treatment session. 77

78 MEDICARE PART B OUTPATIENT SERVICES DOCUMENTATION Treatment or Daily Notes Required for each date of service Does not need to justify medical necessity Elements required for treatment note: Date of service Procedure(s) performed (identify CPT code) Record of time Signature and professional credentials of service provider 78

79 MEDICARE PART B OUTPATIENT SERVICES DOCUMENTATION Progress Note required by CMS minimally every 10th treatment day: Name and credentials of service provider Assessment of progress made toward therapy goals, including objective measurements Treatment plan revisions or modifications Changes to long or short-term goals Functional reporting Current status of patient, Projected status, G-codes and severity modifiers Method of measuring severity (e.g., National Outcome Measurement System) 79

80 MEDICARE PART B OUTPATIENT SERVICES DOCUMENTATION Discharge Note - follows same requirements as Progress Note Functional reporting Current status of patient, Discharge status G-codes and severity modifiers Method of measuring severity (e.g., National Outcome Measurement System) Recertification Required minimally every 90 days Counted from the first day of treatment, unless a state law requires it more frequently. Adheres to the requirements of certification signature. 80

81 MEDICARE PART B SUPERVISION OF STUDENTS &UNLICENSED CLINICAL FELLOWS All covered Medicare services must be provided at a level of complexity that requires a qualified professional for safe and effective care Only services of qualified professional may be billed & paid under Part B Medicare Part B requires 100% personal supervision of SLP students by qualified SLP Must be in the room Must be directing the service Must not be engaged in other activities Students & unlicensed clinical fellows are considered extensions of qualified practitioner Does NOT apply to non-medicare settings unless specified Medicare supervision requirements do not replace any STATE supervision regulations or requirements 81

82 MEDICARE CONUNDRUMS When A becomes B and B becomes A 82

83 HOSPITAL OBSERVATION STATUS PART B MAY BECOME PART A OR NOT Observation services are hospital outpatient services rendered while the doctor decides whether to admit the person as an inpatient or discharge them. Observation services can be rendered in the emergency department or another area of the hospital. The decision for inpatient hospital admission is a complex medical decision based on the doctor s judgment and the need for medically necessary hospital care. Two midnights Qualifying diagnosis 83

84 SKILLED NURSING FACILITIES PART A TO PART B IN SNFS Medicare Part B reimbursement begins after first 100 days under Part A Services under Part B billed using CPT codes Not a prospective payment system Most procedures provided by SLPs are untimed under Part B 84

85 HOW TO USE ICD-10 AND CPT CODES Coding practice 85

86 CASE SCENARIO CPT CODING QUESTION The patient had a cerebral infarct and presents with aphasia and dysarthria. Which evaluation procedure code(s) is/are your best choices? A. CPT (speech sound production with receptive & expressive language) B. CPT (aphasia assessment per hour) and CPT (speech sound production) C. CPT and CPT

87 CASE SCENARIO CPT CODING ANSWER Best choice of evaluations for CVA and dysarthria: Choice B CPT (aphasia assessment per hour) and CPT (speech sound production) Use -59 modifier on the second procedure 87

88 CASE SCENARIO ICD-10 CODING QUESTION The patient had a cerebral infarct and presents with aphasia and dysarthria. Which diagnostic code (s) (ICD-10) is/are your best choice? A. I Aphasia following cerebral infarction I Dysarthria following cerebral infarction B. I69.32 Speech and language deficits following cerebral infarction C. R47.01 Aphasia R47.1 Dysarthria and anarthria 88

89 CASE SCENARIO ICD-10 CODING ANSWER Answer is : A I Aphasia following cerebral infarction I Dysarthria following cerebral infarction I69.32 is not the most specific code choice R47 codes have an Excludes 1 excluding aphasia and dysarthria following cerebrovascular disease I69. 89

90 CASE SCENARIO CPT CODING QUESTION Ms. Jones has Parkinson s disease and presents with impairment of expressive/receptive language, motor speech and voice. Which evaluation procedures are appropriate? A. CPT (speech sound production with expressive/receptive language) and CPT (behavioral and qualitative analysis of voice and resonance) B. CPT and CPT (speech sound production) C. CPT and CPT

91 CASE SCENARIO CPT CODING ANSWER Answer is A CPT (speech sound production with expressive/receptive language) and CPT (behavioral and qualitative analysis of voice and resonance) 91

92 CASE SCENARIO BILLING MULTIPLE UNITS QUESTION The evaluation for cognitive status using standardized measures took 50 mins with the patient. The interpretation and report writing took 30 mins and was documented in the medical record. How many units of CPT (1 hr/ea unit) may be billed for this evaluation? 92

93 CASE SCENARIO BILLING MULTIPLE UNITS ANSWER CPT is a timed code and may be billed in 1-hour units of time for a maximum of two units. To bill a second unit of 96125, 91 minutes (first hour + ½ of second hour + 1 min) must be documented for the evaluation, interpretation, and report. In this case 80 mins are documented in the record. It is appropriate to bill only one unit of CPT

94 CASE SCENARIO ICD-10QUESTION A child with diagnosis of autism is referred for a speechlanguage evaluation. Assessment measurements indicate that the child has a language deficit. How should the SLP code the diagnosis? A. F84.0 Autistic disorder B. F80.2 Mixed receptive-expressive language disorder C. R48.8 Other symbolic dysfunctions (primary diagnosis) F84.0 Autistic disorder (secondary diagnosis) 94

95 CASE SCENARIO ICD-10 ANSWER The answer is C R48.8 Other symbolic dysfunctions (primary diagnosis) F84.0 Autistic disorder (secondary diagnosis) Use symbolic dysfunction rather than F80.2 (Mixed receptive-expressive language disorder) since there is an underlying disorder contributing to the language problems. F80.2 is in the developmental section. Note: Autism code no longer requires additional digit for current/active state or residual state 95

96 CASE SCENARIO ICD-10 QUESTION I am providing treatment for impairments due to dementia. I used to code for other symbolic dysfunction. What do I code under ICD-10-CM? SLPs used to code ICD X series to describe organic speech-language problems and cognitivecommunication problems 96

97 CASE SCENARIO ICD 10 ANSWER R48.8 Other symbolic dysfunctions Acalculia* Agraphia* *these are examples only R48.8 can be used to capture neurological language impairments when there is documented neurological information to support the diagnosis. Unless caused by stroke (I69.-) 97

98 CASE SCENARIO ICD10 QUESTION A 5-year old child was referred to SLP by pediatrician for evaluation of unintelligible speech. ICD-10 code from the physician was F80.0. Evaluation of speech sounds production was completed and child s articulation was within normal limits. What is the correct ICD-10 code for the evaluation? A. R 47.1 Dysarthria B. O.0X0X Normal C. F80.0 Phonological disorder 98

99 CASE SCENARIO ICD-10 ANSWER The answer is C Phonological Disorder There in NO CODE to indicate normal Explain results in the documentation 99

100 CASE SCENARIO EMERGENCY DEPARTMENT QUESTION The SLP was called to the ED to evaluate the swallow function of an elderly patient who came in with mental status changes. A stroke was r/o and patient was not admitted. SLP evaluation revealed normal swallow. What is required as part of your documentation? A. A plan of care that supports services are individualized, reasonable and necessary. B. G-codes for current status and projected long term goals. C. G-codes for current, projected, and discharge status. D. Since it is covered under DRG, G-codes and plan of care are not necessary. 100

101 CASE SCENARIO EMERGENCY DEPARTMENT ANSWER Answer is: Choice C, G-Codes for current status, projected and discharge status. The patient was not admitted into the hospital but was discharged home. That ED visit is considered an outpatient service and Medicare B rules apply. Patient received evaluation only. Patient will not be seen for treatment and is being discharged. 101

102 PLEASE JOIN US! Ask the Experts about SLP Billing, Coding, and Documentation Session #1054 Today, 1:30 2:30 pm Hyatt Regency Denver, Centennial Ballroom E ICD-10 and Reimbursement Hot Topics for SLPs Session #1495 Friday, 5:00 6:00 pm Convention Center, Mile High 2A-3A 102

103 FOR FURTHER QUESTIONS 103