Compliance for SLPs: Regulatory / Reimbursement Updates & Practical Applications

Transcription

1 Compliance for SLPs: Regulatory / Reimbursement Updates & Practical Applications Anita Halvorsen, MBA, MS, CCC-SLP Aura Reitneris, MA, CCC-SLP ASHA 2006

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3 OBJECTIVE 2

4 DISCUSSION OVERVIEW Regulatory oversight Charge practices Reimbursement Other Advocacy opportunities Q & A 3

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6 OFFICE OF INSPECTOR GENERAL Authority and Federal Register Notices Publications Reports Hearing Testimony Fraud Prevention and Detection Reading Room Organization 5

7 COMPLIANCE GUIDANCES Hospitals Nursing Facilities Laboratories Individual and Small Group 1998 Home Health Agencies 2000 Physician practices Third Party Medical Billing companies DME Ambulance companies 1999 Hospice 2003 Pharmaceutical manufacturers Medicare+Choice organizations Supplemental: Hospitals 2005 (Draft) PHS Research awards 6

8 BASIC ELEMENTS HOSPITAL COMPLIANCE PROGRAM 1. Written standards of conduct 2. Designation of Corporate Compliance Officer and oversight bodies 3. Regular and effective education and training 4. Maintenance of process to receive complaints and a process to protect anonymity of complainant and protect whistleblower from retaliation 5. Development of a system to respond to allegations of improper/illegal activities and enforcement of appropriate disciplinary actions 6. Audit to monitor compliance 7. Investigation and remediation of identified problems and development or policies addressing non-employment or retention of sanctioned individuals 7

9 SUPPLEMENTAL HOSPITAL GUIDANCE Focus on liability risks: Submitting claims and information Anti-kickback and physician self-referral Payments to reduce or limit services EMTALA Substandard care Relationship with federal healthcare program beneficiaries HIPAA Billing Medicare/Medicaid in excess of usual charges 8

10 DEFINITIONS: FRAUD & ABUSE Fraud = Intentional deception or misrepresentation that is made, knowing it is false Could result in unauthorized payment Attempt alone is fraud Abuse = Actions inconsistent with accepted, sound practice 9

11 FALSE CLAIMS ACTS Federal State Local 10

12 DEFINITION: FALSE CLAIM Any person who knowingly presents, or causes to be presented a false or fraudulent claim for payment or approval makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved conspires to defraud the Government by getting a false or fraudulent claim allowed or paid 11

13 FALSE CLAIM (cont d) Knowing and knowingly defined (1) has actual knowledge of the information; (2) acts in deliberate ignorance of the truth or falsity of the information; or (3) acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required. 12

14 CMS: FEDERAL / LOCAL Centers for Medicare and Medicaid Services Regulations and Guidance Manuals Medicare General Information, Eligibility and Entitlement Manual Medicare Benefit Policy Manual Ch 15-Covered Medical and Other Health Services Medicare National Coverage Determinations Manual Medicare Claims Processing Manual Chapter 5 - Part B Outpatient Rehabilitation and CORF Services Medicare Program Integrity Manual Specific Fiscal Intermediary Local Coverage Determinations 13

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16 ASHA Reference: 15

17 PRACTICE: ASHA PREFERRED PRACTICE PATTERNS Speech-Language Screening Children, Adults Swallowing Screening Audiologic Screening Consultation, Counseling Follow-Up Procedures Prevention Services Elective Communication Modification Comprehensive Speech-Language Assessment Communication Assessment/Intervention Infants and Toddlers Preschool Speech-Language and Communication Assessment / Intervention Speech Sound Assessment/Intervention Spoken and Written Language Assessment/Intervention School-Age Children and Adolescents Speech-Language Assessment for Individuals Who Are Bilingual and/or Learning English as an Additional Language Spoken and Written Language Assessment/Intervention Adults Cognitive-Communication Assessment/Intervention Severe Communication Impairment Assessment/Intervention Augmentative and Alternative Communication (AAC) Assessment / Intervention Prosthetic/Adaptive Device Assessment/Intervention Fluency Assessment/Intervention Motor Speech Assessment/Intervention Adults Voice Assessment/Intervention Resonance and Nasal Airflow Assessment/Intervention Orofacial Myofunctional Assessment/Intervention Swallowing and Feeding Assessment/Intervention Children Swallowing Function Assessment/Intervention Adults Assessment of Cognitive-Communication &/or Language Abilities Associated With Auditory Processing Disorders (APD) Intervention for Cognitive-Communication &/or Language Abilities Associated With Auditory Processing Disorders (APD) Aural Rehabilitation Assessment/Intervention 16

18 ASHA POSITION STATEMENTS Adults With Learning Disabilities: A Call to Action Facilitated Communication Identification of Children and Youths With Language Learning Disorders Vocal Tract Visualization and Imaging In-Service Programs in Learning Disabilities Interdisciplinary Approaches to Brain Damage Issues in the Delivery of Services to Individuals With Learning Disabilities Language Learning Disorders Learning Disabilities: Issues in the Preparation of Professional Personnel Instrumental Diagnostic Procedures Swallowing Swallowing and/or Feeding Disorders Social Dialects and Implications of the Position on Social Dialects Learning Disabilities and the Preschool Child Clinical Services via Telepractice Medicaid Guidance for Speech-Language Pathology Services: Addressing the "Under the Direction of" Rule Need for Subject Descriptors in Learning Disability Research: Preschool Through High School Oral and Oropharyngeal Prostheses Service Delivery to Infants, Toddlers, and Their Families Providing Appropriate Education for Students With Learning Disabilities in Regular Education Classrooms Provision of Instruction in English as a Second Language by Speech-Language Pathologists in School Settings Assessment and Management of Oral Myofunctional Disorders Reading and Writing in Children and Adolescents Diagnosis, Assessment, Treatment of Autism Spectrum Disorders Life Span Training, Use, and Supervision of Support Personnel Voice Prostheses Tracheotomized Persons Ventilatory Dependence Students Professionals English With Accents Nonstandard Dialects Service Delivery for Persons With Mental Retardation/Developmental Disabilities Evaluation and Treatment for Tracheoesophageal Puncture and Prosthesis Performance Interpretation of Endoscopic Evaluation of Swallowing Identification, Diagnosis, and Treatment of Cognitive-Communication Disorders Neonatal Intensive Care Unit Augmentative and Alternative Communication Individuals With Dementia-Based Communication Disorders Workload Analysis Approach for Establishing Speech-Language Caseload Standards in the School 17

19 ASHA (PRACTICE) GUIDELINES Admission/Discharge Criteria in Speech-Language Pathology Clinical Indicators for Instrumental Assessment of Dysphagia Guidelines for Practice in Stuttering Treatment Terminology Pertaining to Fluency and Fluency Disorders Guidelines for Speech-Language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders Across the Life Span Guidelines for Speech-Language Pathologists Performing Videofluoroscopic Swallowing Studies Guidelines for Speech-Language Pathologists Persons With Language, Socio-Communication, and/or Cognitive-Communication Impairments Guidelines for Structure and Function of an Interdisciplinary Team for Persons With Brain Injury Guidelines for the Roles and Responsibilities of the School-Based Speech-Language Pathologist Guidelines for the Training, Use, and Supervision of Speech-Language Pathology Assistants Instrumental Diagnostic Procedures for Swallowing Training Guidelines for Laryngeal Videoendoscopy/Stroboscopy Medicaid Guidance for School-Based Speech-Language Pathology Services: Addressing the "Under the Direction of" Rule Oral and Oropharyngeal Prostheses: Guidelines Orofacial Myofunctional Disorders: Knowledge and Skills Role of the Speech-Language Pathologist in the Performance and Interpretation of Endoscopic Evaluation of Swallowing: Guidelines Roles and Responsibilities of Speech-Language Pathologists in the Neonatal Intensive Care Unit Roles and Responsibilities of Speech-Language Pathologists Serving Persons With Mental Retardation/Developmental Disabilities Roles and Responsibilities of Speech-Language Pathologists Reading and Writing for Children and Adolescents: Practice Guidelines Use of Voice Prostheses in Tracheotomized Persons With and Without Ventilatory Dependence Workload Analysis Approach for Establishing Speech-Language Caseload Standards in the Schools 18

20 PRACTICE: STATE All states regulate SLPs. True or False? States that regulate SLPs do so via registration and licensure. All states that license SLPs require continuing education for license renewal. 19

21 FLORIDA LICENSING ACTIONS CHAPTER 468, MISCELLANEOUS PROFESSIONS AND OCCUPATIONS, PART I, SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY (ss ) SLPs: 5200 active, 244 delinquent SLPAs: 312 active, 100 delinquent Provisional SLPs: 458 active, 1 delinquent 81 active CE providers, 661 courses submitted 25 complaints against SLPs, 11 legally sufficient, 12 completed investigations (3 found probable cause, 1 limited license, 1 fine) 0 malpractice claims 0 student loan defaults Reference: Florida Department of Health Division of Medical Quality Assurance, Annual Report 20

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23 QUALITY/SAFETY: (Federal) COPs CMS Conditions of Participation Nursing Services Sec Condition of participation: Nursing services. The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. [[Page 487]] (a) Standard: Organization. The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. (b) Standard: Staffing and delivery of care. The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient. (1) The hospital must provide 24-hour nursing services furnished or supervised by a registered nurse, and have a licensed practical nurse or registered nurse on duty at all times, except for rural hospitals that have in effect a 24-hour nursing waiver granted under Sec (c) of this chapter. (2) The nursing service must have a procedure to ensure that hospital nursing personnel for whom licensure is required have valid and current licensure. (3) A registered nurse must supervise and evaluate the nursing care for each patient. (4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. (5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. (6) Non-employee licensed nurses who are working in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of the clinical activities of non-employee nursing personnel which occur within the responsibility of the nursing service. (c) Standard: Preparation and administration of drugs. Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under Sec (c), and accepted standards of practice. (1) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. (2) All orders for drugs and biologicals must be in writing and signed by the practitioner or practitioners responsible for the care of the patient as specified under Sec (c) with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved hospital policy after an assessment for contraindications. When telephone or oral orders must be used, they must be-- (i) Accepted only by personnel that are authorized to do so by the medical staff policies and procedures, consistent with Federal and State law; (ii) Signed or initialed by the prescribing practitioner as soon as possible; and (iii) Used infrequently. (3) Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. If blood transfusions and intravenous medications are administered by personnel other than doctors of medicine or osteopathy, the personnel must have special training for this duty. (4) There must be a hospital procedure for reporting transfusion reactions, adverse drug reactions, and errors in administration of drugs. 22

24 QUALITY/SAFETY: (Federal) COPs Rehabilitation Services If the hospital provides rehabilitation, physical therapy, occupational therapy, audiology, or speech pathology services, the services must be organized and staffed to ensure the health and safety of patients. (a) Standard: Organization and staffing. The organization of the service must be appropriate to the scope of the services offered. (1) The director of the services must have the necessary knowledge, experience, and capabilities to properly supervise and administer the services. (2) PT, OT, SLP, or AUD services, if provided, must be provided by staff who meet the qualifications specified by the medical staff, consistent with State law. (b) Standard: Delivery of services. Services must be furnished in accordance with a written plan of treatment. Services must be given in accordance with orders of practitioners who are authorized by the medical staff to order the services, and the orders must be incorporated in the patient's record. 23

25 QUALITY/SAFETY: (State) PUBLIC HEALTH Illinois Department Public Health Rehabilitative Care: Each allied health service shall have documented in the medical chart patient assessment, care plans, objectives and follow-up plans, and shall provide evaluative, therapeutic and follow-up programs, working in coordination with other services, under the overall direction of an appropriately qualified physician, for the purpose of maximizing patient self-care and independence. It is recommended that hospitals provide appropriate, current and accessible reference materials as guides for the specific restoration services offered. Radiology: The use of all radiological apparatus shall be limited to personnel designated as qualified by the physician responsible for the direction and/or supervision of the department or service. The use of fluoroscopes shall be limited to credentialed physicians. 24

26 QUALITY/SAFETY: JCAHO Joint Commission on the Accreditation of Healthcare Organizations Do not use list National Patient Safety Goals (relevant to SLPs) 1. Improve the accuracy of patient identification 2. Improve the effectiveness of communication among caregivers 3. Improve the safety of using medications 4. Reduce the risk of health care-associated infections 5. Accurately and completely reconcile medications across the continuum of care 6. Reduce the risk of patient harm resulting from falls 25

27 QUALITY/SAFETY: CARF Commission on Accreditation of Rehabilitation Facilities Adult Day Services Alcohol and Substance Abuse Treatment Assisted Living Residences Assistive Technology Services Blind Rehabilitation Services Child and Youth Services Community Services Continuing Care Retirement Communities Day Habilitation Services Employment Services Employee Assistance Programs Mental Health Services (also called Behavioral Health) Methadone Treatment (also called Opioid Treatment) One-stop Career Centers Pain Management Physical Rehabilitation (also called Medical Rehabilitation) Supported Living (for Community Services) Supported Living (for Behavioral Health) 26

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29 CHARGED VS. BILLED What is the difference between what is charged versus what is billed? Charged = information that is entered by the therapist to represent what procedures were completed Billed = information that is dropped on the patient s bill and is sent to the payer 28

30 CPT CODES CPT = Current Procedural Terminology Purpose: Provide a uniform language to describe medical, surgical, and diagnostic services The CPT nomenclature is maintained by the CPT Editorial Panel The CPT Advisory Committee supports the CPT Editorial Committee 29

31 TIME BASED VS. VISIT BASED / UNTIMED CODES Visit Based / Untimed Codes: For visit based or untimed codes, units are billed based on the number of times the procedure is performed. Note: Often these codes are performed one time per day Example: A therapist completes an evaluation (visit based code). Regardless of the number of minutes it takes to perform this evaluation, this code is dropped as a unit of one (1) on the patient bill. 30

32 CPT CODES True or False? All CPT codes used by Speech-Language Pathologists are visit based/untimed. 31

33 TIME BASED VS. VISIT BASED / UNTIMED CODES Time Based Codes: Most therapy time based codes are measured in 15 minute units. Per Medicare regulations, therapists will charge a 15 minute unit for treatment greater than or equal to 8 minutes. Time intervals for 15 minute units, per Medicare, are as follows: 1 unit: > 8 minutes - 22 minutes 2 units: > 23 minutes - 37 minutes 3 units: > 38 minutes - 52 minutes 4 units: > 53 minutes - 67 minutes 5 units: > 68 minutes - 82 minutes 6 units: > 83 minutes - 97 minutes 7 units: > 98 minutes minutes 8 units: > 113 minutes -127 minutes 32

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35 SLP EVALUATIONS CODES Evaluation of Speech, Lang, Voice, Communication &/or Aud Processing CPT Description: Evaluation of speech, language, voice, communication, and/or auditory processing disorder Visit Based Code Evaluation for Use and/or Fitting of Voice Prosthetic Device to Supplement Oral Speech CPT Description: Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech Visit Based Code Question: Should this code be used when evaluating a patient for a Passy Muir Valve or TEP? Answer: Per ASHA, this code should be used for TEP and PMV evaluations. 34

36 SLP EVALUATIONS CODES Evaluation for Non-Speech Generating AAC Device CPT Description: Evaluation for prescription of non-speech generating augmentative and alternative communication device Visit Based Code Evaluation for Speech Generating Device CPT Description: Evaluation for prescription for speech generating augmentative and alternative communication device, face-to-face, first hour Time Based Code (per hour) Each additional 30 minutes

37 SLP EVALUATIONS CODES Evaluation of Oral and Pharyngeal Swallow Function CPT Description: Evaluation of oral and pharyngeal swallow function Visit Based Code This code should be used for a clinical swallow evaluation Motion Fluoroscopic Evaluation of Swallowing (by cine or video recording) CPT Description: Motion fluoroscopic evaluation of swallowing function by cine or video recording Visit Based Code 36

38 SLP EVALUATIONS CODES FEES CPT Description: Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording Visit Based Code Assessment of Aphasia CPT Description: Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and report Time Based Code (per hour) Question: When is it appropriate to use vs ? Answer: When completing a formal evaluation of aphasia (elements listed above), it is appropriate to use the code. When completing a general speech-language evaluation, utilize the code. 37

39 SLP THERAPY CODES Treatment of Speech, Language, Voice, Communication &/or Aud Processing, Individual CPT Description: Treatment of speech, language, voice, communication and/or auditory processing; individual Visit Based Code Treatment of Speech, Language, Voice, Communication &/or Aud Processing, Group CPT Description: Treatment of speech, language, voice, communication and/or auditory processing; group, 2 or more individuals Visit Based Code 38

40 SLP THERAPY CODES Treatment of Swallowing Dysfunction &/or Oral Function for Feeding CPT Description: Treatment of swallowing dysfunction and/or oral function for feeding Visit Based Code 39

41 SLP THERAPY CODES Treatment of Non-Speech Generating AAC Device CPT Description: Therapeutic services for the use of non-speech generating devices, including the programming and modification Visit Based Code Treatment for the Use of a Speech Generating Device CPT Description: Therapeutic services for the use of speech generating devices, including the programming and modification Visit Based Code 40

42 SLP THERAPY CODES Audiology Screening Test, Pure Tone CPT Description: Screening test, pure tone, air only Visit Based Code Service includes testing of both ears Cognitive Therapy CPT Description: Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training) Time based code; each 15 minutes Requires direct one-on-one patient contact by the provider Question: Can a patient be charged both and on the same day? Answer: Per ASHA s website: Regarding (cognitive skills development), Medicare allows usage by speech-language pathologists, but not on the same day as

43 ICD-9-CM CODES The International Classification of Diseases, 9 th Revision, Clinical Modification Volume 1 Diseases: Tabular List Volume 2 Disease: Alphabetic Index Volume 3 Procedures: Tabular List and Alphabetic List Intent: To standardize disease and procedure classification These codes are maintained by representatives of: The National Center for Health Statistics The American Hospital Association The American Health Information Management Association CMS 42

44 ICD-9-CM CODES Only a physician can provide a medical diagnosis when referring a patient for therapy This diagnosis may or may not provide the reason why the patient requires skilled therapy services Depending on state and/or local laws, a treatment/therapy diagnosis may be provided by the therapist based on the results of the evaluation This treatment diagnosis should provide the reason the patient requires skilled therapy (may be the same as the medical diagnosis provided by the physician). 43

45 ICD-9-CM CODES Depending on your place of employment, identifying an appropriate therapy/treatment diagnosis may be the responsibility of a/n: Speech-Language Pathologist (the therapist) Administrative Coordinator Manager Certified Coder ICD-9 CODES Other 44

46 ICD-9-CM CODES If it is the SLP s responsibility to identify a treatment diagnosis, where can he/she look for guidance?»icd-9-cm Reference (current edition)»professional Organization (ASHA)»Coding books for rehabilitation/therapy services»lcds 45

47 ICD-9-CM CODES Why is it important that to have the correct treatment diagnosis code? Payers look to the ICD-9-CM codes to explain the medical and/or treatment diagnosis that warrants the need for skilled therapy services Some payers will provide lists of ICD-9-CM codes that they feel support medical necessity 46

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49 NCCI EDITS NCCI = National Correct Coding Initiative Purpose: Minimize abusive and fraudulent billing Updated quarterly on the CMS website Private Practice / Physician Owned Settings use NCCI Edits Physicians All other settings use NCCI Edits Hospital Outpatient PPS 48

50 NCCI EDITS Mutually Exclusive Edits: Relate to procedures or services that are not reasonably performed on the same day by the same provider Column 1 / Column 2 Edits: CPT codes in Column 2 are often considered part of the more comprehensive codes in Column 1 49

51 NCCI EDITS Column 1 Column 2 Mutually Exclusive Edits * = In existence prior to 1996 Effective Date Deletion Date *=no data Modifier 0=not allowed 1=allowed 9=not applicable * 1 filterbydid=-99&sortbydid=2&sortorder=ascending&itemid=cms

52 NCCI EDITS Column 1 Column 2 Column1/Column 2 Edits * = In existence prior to 1996 Effective Date Deletion Date *=no data Modifier 0=not allowed 1=allowed 9=not applicable * * 1 filterbydid=-99&sortbydid=2&sortorder=ascending&itemid=cms

53 THERAPY MODIFIERS What is a modifier? 2 digit (alpha or numeric) code placed at the end of a CPT code to help convey specific information about the procedure, such as: Who provided the service How the service was provided 52

54 THERAPY MODIFIERS Effective January 1, 2003, one of the following therapy modifiers must be provided for all therapy services billed: GN - Services delivered under an outpatient speech-language pathology plan of care GO - Services delivered under an outpatient occupational therapy plan of care. GP - Services delivered under an outpatient physical therapy plan of care. Note: Therapy modifiers assure that services are performed by Medicare recognized providers. 53

55 THERAPY MODIFIERS Modifier -22: Unusual Procedural Service The service provided is greater than what is usually provided for the procedure. Example: If an evaluation takes an exceptionally long time to complete due to the patients impairments, a -22 modifier can be attached to the CPT code on the claim. *Caution: Adding a -22 modifier may elicit a review or audit by the payer. Assure that documentation supports/explains the use. 54

56 THERAPY MODIFIERS Modifier -52: Reduced Services The provider reduces or eliminates a portion of the service. Example: If an SLP completes an evaluation for a speech generating device (92607) but completed the evaluation in less than an hour, they may add a -52 modifier to the CPT code. *Caution: Adding the -52 modifier will result in a reduction in reimbursement. 55

57 THERAPY MODIFIERS Modifier -59: Distinct Procedural Service Indicates that a procedure was distinct and separate from another service provided on the same day Example: If an SLP sees a patient in a group for 30 minutes then completes an individualized session for 30 minutes, a -59 modifier should be used as these procedures are viewed as mutually exclusive *Caution: Overuse of a -59 modifier may trigger an audit or review of documentation. 56

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59 FUTURE Medically Unlikely Edits (MUE) Project: Originally referred to as Medically Unbelievable Edits Purpose: To allow CMS to identify and deny unlikely Medicare claims in a pre-payment basis Example of UNLIKELY 4 units of an Assessment of Aphasia Why? Each unit for an assessment of aphasia is = 1 hour Not in place yet. Potential for Spring/Summer CMS will continue to use its website and listserves to communicate information re: this initiative. 58

60 REASONABLE & NECESSARY Per CMS Medicare Benefits Policy Manual, in order for services to be considered reasonable and necessary they must meet certain requirements. It is the SLP s responsibility to assure that these requirements are met and documented appropriately. 59

61 REASONABLE & NECESSARY REQUIREMENTS Services must be considered specific and effective for the patient s condition. CMS references the following to find acceptable practices: Medicare Manuals Local Coverage Determination Guidelines and literature of the speech-language pathology profession 60

62 REASONABLE & NECESSARY REQUIREMENTS Services must be of the level of complexity that they could only be performed safely and effectively by a qualified Speech-Language Pathologist. If they do not require the skills of an SLP, they are NOT considered reasonable or necessary. 61

63 REASONABLE & NECESSARY REQUIREMENTS Skills of a SLP are needed to manage and potentially reevaluate the need for a maintenance program There must be an expectation for improvement in a reasonable and generally predictable time period Amount, frequency and duration of a treatment plan must be acceptable under standards of practice 62

64 REASONABLE & NECESSARY Remember, a medical condition or diagnosis is not enough to prove medical necessity. Services will be denied if they are NOT considered to be reasonable and necessary! 63

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66 SUPERVISION & GUIDANCE SLP Students: An student/applicant must complete a minimum of 400 hours of supervised clinical experience in the filed of speech-language pathology 25 hours in clinical observation 375 hours in direct client/patient contact At least 325 must be completed while the applicant in engaged in graduate study in a program accredited in Speech-language pathology Supervision must be in real time and never less than 25% of the student s total contact with each client/patient. * Per ASHA, requirements should be adjusted upward if the student s level of knowledge requires such! 65

67 SUPERVISION & GUIDANCE Clinical Fellows (CFYs): Supervision must be completed by an individual holding a valid CCC throughout the entire period of supervision Must involve personal and direct involvement by the supervisor The supervisor must complete at least 36 supervisory activities throughout the clinical fellowship 18 on site observations (an observation is one hour) Six (6) must be accrued during each third of the experience 18 other monitoring activities (meetings to discuss clinical strategies, monitoring of contributions to professional meetings, monitoring of participation in case conferences, etc) Six (6) during each third of the experience 66

68 SUPERVISION & GUIDANCE SLP-Assistants (SLPAs): Supervising SLP must have: practiced for at least 2 years following ASHA certification completed at least one course or continuing education unit in supervision. Minimum of 30% direct and indirect supervision per week for the first 90 days. Direct supervision of patient care should be no less than 20% of scheduled actual patient contact time weekly. Indirect supervision may include demonstration, record review, review of audio/video-taped sessions, interactive television or telephone conference. After 90 days, minimum 20% supervision weekly (with no less than 10% weekly being direct). All patients must receive some direct contact w/ the SLP at least once every 2 weeks. Amount and type of supervision must be documented. 67

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70 SLP MEDICARE REIMBURSEMENT 101 Setting Acute / Medical- Surgical LTCH SNF IRF HH OP Hospital OP Clinic Payment DRG Per Per Per Per 60-day MPFS Financial Diem; Diem; Discharge; Episode; Limitation DRGs RUGs CMGs National Rate 69

71 RECENT ACTIONS Inpatient Rehabilitation Medical Necessity audits 2003, 2004, 2005 and 2006 OIG Work Plans (auditing at FI level) Nationwide Review of Compliance With the Interrupted Stay Provision of the Inpatient Rehabilitation Facility Prospective Payment System for Calendar Years 2002 and 2003 (December 2005, A ) 70

72 RECENT ACTIONS Outpatient Rehabilitation Billing Review of Comprehensive Outpatient Rehabilitation Facility Therapy Services Provided by ABC Total Rehabilitation Care, Inc. (October 2006, A ) Use of Modifier 59 to Bypass Medicare's National Correct Coding Initiative Edits (November 2005, OEI ) Home Health Review of Compliance with Billing Provisions Under the Prospective Payment System for Home Health Agencies Therapy Services Pacific Home Health Care, Inc. (September 2006, A ) 71

73 UPCOMING ACTIONS Financial Limitation (aka, Therapy Cap) Automatic Exceptions Certain evaluation services Certain conditions and complexities (when supported by documentation) Additional exceptions are allowed Manual Exceptions By formal request 72

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75 ADVOCACY: NATIONAL ASHA Issue Briefs SLP Medicare Outpatient Supplier Status Medicare Outpatient Therapy Caps Focused Initiatives Personnel Issues in Healthcare and Education SLP Advocate Blank to 74

76 ADVOCACY: STATE ASHA STARs: State Advocates for Reimbursement Florida: Pete Johnson, Stacie Rubin Smith MICS: Medicare Intermediary and Carrier State Network Florida: Pete Johnson, Stacie Rubin Smith Personal Experience?? 75

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