MEDICARE IMPROVEMENTS FOR PATIENTS AND PROVIDERS ACT OF 2008 (MIPPA) UNIVERSITY SPEECH AND HEARING CLINICS MEDICARE REQUIREMENTS Dee Adams Nikjeh, PhD ASHA Health Care Economics Committee, Co-Chair AMA Health Care Professionals Advisory Committee, ASHA Relative Value Update Alternate Advisor University of South Florida Training Our Students for the Job Legislative act granted independent provider status for SLPs July 1, 2009 SLPs could directly bill Medicare Prior to MIPAA, SLP code values were based primarily on practice expense only SLP procedure codes (CPT codes) could now be valued to include professional work Robert C. Fifer, PhD ASHA Health Care Economics Committee AMA Health Care Professionals Advisory Committee, ASHA Relative Value Update Advisor University of Miami SLP CPT CODES WITH PROFESSIONAL WORK VALUE HOW TO BECOME A MEDICARE PROVIDER STEP 1 92507 Speech & language tx 92508 Speech & language tx, group 92526 Dysphagia Tx 92597 Voice prosthetic eval 92606 Non-speech generating device tx services 92607 Speech generating device, Eval, 1 st hour 92608 each additional 30 mins 92609 Speech-generating device tx services 92610 Eval of swallowing function 92611 Motion fluoroscopy /swallow 92612 Endoscopy swallow test (FEES) 92614 Laryngoscopic sensory test 96105 Assessment of aphasia, per hour 96111 Developmental test, extended 96125 Standardized cognitive performance testing, per hour Obtain a National Provider Identifier (NPI) 10-digit number required under HIPAA for health care providers Apply on-line or call : 1-800-4653203 Provider type is 23 (speech, language, hearing service provider) Taxonomy number for audiologist is 231H00000X Taxonomy number for SLP is 235Z00000X Group practice Type II-NPI To enroll: https://nppes.cms.hhs.gov/nppes/staticforward.do?forward=static.in structions For more information: http://www.asha.org/members/issues/reimbursement/hipaa/npi.ht m HOW TO BECOME A MEDICARE PROVIDER STEP 2 HOW TO BECOME A MEDICARE PROVIDER STEP 3 Identify a Medicare contractor Carriers or Medicare Administrative Contractor (MAC) Map and fact sheet: http://www.cms.hhs.gov/medicarecontractingreform/downloads/primaryabmacju risdictionfactsheets.pdf http://www.cms.hhs.gov/medicarecontractingreform/downloads/macjurisdictionf actsheet.pdf Submit an enrollment form CMS855i Physicians and NonPhysician Practitioners http://www.cms.hhs.gov/cmsforms/downloads/cms855i.pdf CMS855B Clinics/Group Practices, and Certain Other Suppliers http://www.cms.hhs.gov/cmsforms/downloads/cms855b.pdf Find your MAC http://www.cms.hhs.gov/mlngeninfo/01_overview.asp? Select Provider Call Center TollFree Numbers Directory Select CallCenterTollNumDirectory excel spreadsheet
HOW TO BECOME A MEDICARE PROVIDER STEP 4 Other forms to submit CMS855R Reassignment of Medicare Benefits http://www.cms.hhs.gov/cmsforms/downloads/cms855r.pdf CMS460 Medicare Participating Physician or Supplier Agreement http://www.cms.hhs.gov/cmsforms/downloads/cms460.pdf CMS588 Authorization Agreement for Electronic Funds Transfer http://www.cms.hhs.gov/cmsforms/downloads/cms588.pdf NATIONAL PROVIDER IDENTIFIER (NPI) THINGS TO CONSIDER SLPs and Auds may treat Medicare beneficiaries only if they are enrolled as a Medicare provider University clinic is not a provider Qualified SLPs or Auds are providers Each enrolled SLP & Aud employee or contractor can designate that all payments by assigned to the clinic form CMS-855R Reassignment of Medicare Benefits Federal law requires NPI for electronic billing Exception: Hard copy submission is allowed by practitioners or suppliers that have fewer than 10 FTEs* QUALIFIED PROVIDER DEFINED SPEECH-LANGUAGE PATHOLOGIST Meets one of the following requirements: The education and experience requirements for a Certificate of Clinical Competence in (speech-language pathology) granted by the American Speech- Language Hearing Association; or Meets the educational requirements for certification and is in the process of accumulating the supervised experience required for certification. Clinical Fellows are not licensed in AL, CT, HI, MA, NV, NY, ND,PA,TN, UT Request written acceptance from the carrier/mac DN2 NRS1 QUALIFIED PROVIDER DEFINED AUDIOLOGIST Masters or doctoral degree in audiology AuD 4th year students are not qualified Also must be licensed in state where audiologist provides services If the state does not license audiologists, must have: Successfully completed 350 clock hours of supervised clinical practicum (or is in the process of accumulating such supervised clinical experience), and Performed not less than 9 months of supervised fulltime audiology services after obtaining a master s or doctoral degree in audiology or a related field, and Successfully completed a national examination in audiology approved by the Secretary STUDENTS ARE NOT QUALIFIED PROVIDERS TO BE OR NOT TO BE A MEDICARE PROVIDER Medicare requires 100% personal supervision of SLP or Aud students by qualified SLP or Aud in an out-patient setting (Medicare Part B) Must be in the room Must be directing the service Must not be engaged in other activities Most common reason for a clinic to be excluded from Medicare enrollment is if student services are provided without 100% supervision line-of-site supervision applies only to skilled nursing facility Part A residents Pros Medicare patients may be seen for a wide range of speech and language services May have financial benefits Cons Faculty must be adequately staffed and individual Medicare providers to provide 100% in-the-room supervision* If in most cases there is inadequate supervision, then one should question any rationale for becoming a Medicare provider Advance Beneficiary Notice of Noncoverage (ABN) form will have to be signed whenever the services rendered clearly do not fall within the Medicare scope of coverage (e.g., insignificant functional progress from an ADL practical viewpoint) http://www.cms.gov/bni/02_abn.asp THANK YOU TO MARK KANDER, ASHA S DIRECTOR OF HEALTH CARE REGULATORY ANALYSIS
Slide 9 DN2 NRS1 What is this? Dee Nikjeh, 2/23/2011 Hawaii! NSwanson, 3/9/2011
ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN) MANDATORY CLAIMS SUBMISSION Official ABN at the top states: NOTE: If Medicare doesn t pay for When it is known that services are not covered, ABN may be used to explain & document with the patient why proposed services would not be covered by Medicare (e.g. services rendered by students, insignificant functional progress, service rendered for training purposes only) In this case, the ABN is not signed as a Medicare document because it has been modified to inform patients that services are not covered by Medicare Justifies charging the Medicare beneficiary a direct charge per visit Removes providers obligation to submit a claim when patient signs, acknowledging that the services are not covered by Medicare If an SLP furnishes a Medicare-covered service to a beneficiary, then the SLP is required to submit a claim on the beneficiary s behalf (must be enrolled as Medicare provider) If a university clinic offers services that meet Medicare coverage guidelines, but the clinic will not be able to enroll as a Medicare provider (for whatever reason), then Medicare beneficiaries should not be served for medically necessary therapy services MANDATORY CLAIMS SUBMISSION If a qualified audiologist provides services to a Medicare recipient, and the recipient requests the audiologist to bill Medicare, the audiologist must enroll in Medicare and submit billing. Refusal to submit billing and asking the patient to sign an ABN is not acceptable. There is no opt out privilege for auds. FREQUENTLY ASKED QUESTIONS ABOUT MEDICARE AND UNIVERSITY CLINICS QUESTION: Do private insurance companies follow Medicare regulations? ANSWER Private health plans selectively adopt Medicare coverage policies. All private plans require that services be rendered by a qualified health care practitioner. Rarely do they describe student involvement. It is wise to inform the third party payer of the degree of supervision of students. This will prevent a future audit that could demand thousands of dollars in repayment. FREQUENTLY ASKED QUESTIONS ABOUT MEDICARE AND UNIVERSITY CLINICS QUESTION: If a university clinic does not currently bill private insurance, Medicaid, or Medicare, can it continue to bill patients privately and not bill Medicare (even if the person is a Medicare beneficiary-often after having exhausted Medicare funds)?
ANSWER ANSWER CONTINUED ASHA has received confirmation from CMS that free clinics (i.e., never charge for services) are exempt from Medicare enrollment requirements. If not a free clinic, SLPs and Auds may treat Medicare beneficiaries only if they are enrolled as Medicare providers. Exception: If a beneficiary, of their own free will, instructs a practitioner to not submit a claim to Medicare, the practitioner may treat the patient outside of Medicare. However, there are two significant complications: All beneficiaries must make this demand truly of their own free will. A beneficiary is free to change his or her decision at any time and request that a claim be submitted to Medicare for current and/or past services. If the university does not wish to enroll in Medicare, it is suggested that those who qualify for Medicare benefits should be refused treatment and referred to other practitioners in the community Regarding "exhausted Medicare funds," the annual therapy cap (combined SLP/PT services) has been largely circumvented by Congress because several years ago it established an exceptions process that allows coverage as long as documentation in the medical record clearly shows medically/functionally necessary services. 2011 combined therapy cap for SLP and PT services is $1,870 ASHA has determined that exceeding the cap does not automatically exclude speech-language services from Medicare coverage because of the exceptions process that allows coverage of medically necessary services beyond the cap. ANSWER CONTINUED Medicare benefits are never exhausted for audiology services as long as medically necessary diagnostics are required for patient treatment. The rule of thumb is that the clinic should treat everyone the same with regard to providing services and charging for audiology services because of the no opt out provision for Medicare. FREQUENTLY ASKED QUESTIONS ABOUT MEDICARE AND UNIVERSITY CLINICS QUESTION: Can a clinic that normally bills for Medicare services bill the patient directly for services if the submitted claim has been denied? ANSWER FREQUENTLY ASKED QUESTIONS ABOUT MEDICARE AND UNIVERSITY CLINICS Yes, if the reason for the denial is that the type of service is never covered or the services are not medically necessary. Denials based on technical errors such as improper coding would not apply here. When there is reason to believe that the claim will be denied, be advised that an Advance Beneficiary Notice (ABN) should be signed by the beneficiary before the services are rendered so he/she understands there may be personal financial responsibility if Medicare is not responsible for payment. As an additional note, if the service is statutorily excluded (i.e., hearing aids), Medicare should not be billed unless a denial is necessary for secondary insurance. QUESTION: Many clinics choose not to accept Medicare beneficiaries. Does that require any specific type of notice?
ANSWER FREQUENTLY ASKED QUESTIONS ABOUT MEDICARE AND UNIVERSITY CLINICS No specific type of notice is required. A sign may be posted in the clinic, "We Do Not Treat Medicare Beneficiaries." The sign might be more patient-friendly with a preface, "Due to Difficulty Adhering to Medicare Billing and Coverage Requirements. Be aware that this may be problematic for audiology if insurances are billed or self-pay patients are seen and/or an audiologist at the center is listed as a provider for a company with Medigap coverage. Again, this is due to the opt out provision. QUESTION: Do university clinics need to follow the Medicare student supervision rule (i.e., in the room all of the time and not engaged in other activities) if they provide a 100% discount to all Medicare beneficiaries? ANSWER If all clients (not just Medicare clients) are seen free, the clinic need not enroll in Medicare and thus need not follow the supervision rules. DOCUMENTATION REQUIREMENTS If it wasn t documented, it wasn t done! PRINCIPLES OF DOCUMENTATION MEDICARE GUIDANCE ON DOCUMENTATION Accurate: describes the care provided Code-able: describes services so well that the Current Procedural Terminology(CPT) codes and Diagnostics Codes (ICD) are supported and are appropriate for each other Understandable: clear to reader (and not just to another SLP) Timely: completed soon after the encounter Error-free: stands alone as a legal document Medicare Benefit Policy Manual Publication, 100-02, Chapter 15, Section 220.3 Medicare requires that therapy services are of appropriate type, frequency, intensity, & duration for the individual needs of the patient Documentation should Establish variables that influence the patient s condition establish through objective measurements that the patient is making progress toward goals
MEDICARE GUIDANCE ON DOCUMENTATION COMPONENTS OF EVALUATION REPORT Documentation should include: Evaluation Plan of Care/Certification of Plan of Care Progress Reports Treatment Notes Discharge Note Patient s identifying info Diagnosis & description of specific problem (ICD-9-CM code) what precipitated referral Time In/Time Out Statement of objective, measurable beneficiary physical function (e.g., NOMS, functional assessment scores) Plan of care May be reported in separate document Estimate of potential for significant practical improvements based on evaluation, motivation, cognitive status, level of alertness Signature with professional s ID Date of signature PLAN OF CARE CERTIFICATION/RECERTIFICATION Established by physician, nonphysician practitioner, qualified therapist Established before treatment begins May be written on same day as eval & initial tx session Dictated plan must be signed by COB the next day Components (minimum) Long-term goals developed for entire episode of care, not just one interval of care Diagnosis Type, amount, duration, and frequency of therapy services Signature, date, & professional identity of person who established the plan Certification (and recertification of the plan when applicable) are required for payment Format and method are determined by the individual facility and/or practitioner Certification requires dated signature on plan of care Physician s/npp s certification of the plan (with or without an order) satisfies all of the certification requirements for the duration of the plan of care, or 90 calendar days from the date of the initial treatment, whichever is less Plan of care is recertified every 90 days TREATMENT NOTE TREATMENT NOTE Record all treatments and skilled interventions that are provided Record the time of services in order to justify use of billing codes on claim Required for every treatment day and every therapy service Required Elements: Date of treatment Identification of each specific intervention/modality provided and billed Total treatment time Signature of professional providing service Optional Elements: Patient self-report Adverse reaction to intervention Communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist, etc.) Significant, unusual or unexpected changes in clinical status Equipment provided Any additional relevant information the qualified professional finds appropriate
PROGRESS REPORT DISCHARGE NOTE Must be completed at least once every 10 treatment days or at least once during each certification interval, whichever is less Provides justification for the medical necessity of service Does not require physician signature Components: Assessment of improvement and progress towards goals Plans for continuing treatment, reference to additional evaluation results, and/or Treatment plan revisions Modification of goals as needed Prognosis Same as progress report and covers the reporting period from the last progress report to the date of discharge Indicate that therapist reviewed the notes and agrees to the discharge AUDIOLOGY DOCUMENTATION DOCUMENTATION Reference source: 1997 Documentation Guidelines for Evaluation and Management Services (https://www.cms.gov/mlnproducts/downloads/master1.pdf) History Description of service and findings Clinical assessment Recommendations Signature and date of service Harmony between procedure, code selection and documentation Documentation supports code selection Justifies reporting specific code Clarifies medical necessity Records special circumstances PITFALL: DOCUMENTATION DOCUMENTATION REQUIREMENTS Often inadequate Consists of audiogram with some notes Ex: Referred by Dr. Razzelfratz for hearing test. Recommend hearing aids Fails to meet federal guidelines for minimum documentation standards for covered services Medicare requirements: Name of referring physician Reason for referral Referral Audiological report Patient s medical record
DOCUMENTATION REQUIREMENTS DOCUMENTATION REQUIREMENTS Medicare requirements (cont.) Documentation should: indicate that the test was ordered, that the reason for the test results in coverage, that the test was furnished to the patient by a qualified individual. Records that support the appropriate provision of an audiological diagnostic test shall be made available to the contractor on request. Issues: Medical necessity for why the patient is there Referred by is not medical necessity Requires a history covering the following areas as appropriate Chief Complaint Duration of symptoms Family history Social / occupational history Prior medical history Relevant diagnoses This section justifies all that is done DOCUMENTATION REQUIREMENTS Issue Describing what was done The audiogram cannot stand on its own Most professionals don t know what it is or what it means Description of procedures and observations Procedure description can be canned Description of what was found (results) DOCUMENTATION REQUIREMENTS Issue Clinical Assessment Must have a clear statement of practical and clinical significance Must flow logically from the history and the findings Recommendations Logical conclusion to the matter. Based on these outcomes, the following recommendations are offered: Each recommendation must be supported by history, findings, and interpretation Do not list unsupported recommendation ADDITIONAL NOTES ON RECOMMENDATIONS OTHER REQUIREMENTS Issue Medical Necessity All recommendations must be supported by the concept of medical necessity Recommendation should not be offered that is for the convenience of audiologist or patient Automatic annual re-checks without justification not appropriate. Justification may include: Known or suspected risk for change in status Unrelated diagnosis that may impact patient s status Change in symptoms Presentation of new symptoms Signature If a paper report, must be an original signature Facsimile or stamped signature is not appropriate If electronic medical record (EMR), your login constitutes your signature Date Date of service must be specified and prominent in report Other dates may include date of review, date of signing, date of dictation. These must be distinguished from date of service. Date requirement re EMR
OVERVIEW: CODING AND REIMBURSEMENT ASHA CODING, REIMBURSEMENT, AND ADVOCACY MODULES INTRODUCTION An Introduction to the Series of Coding, Reimbursement, & Advocacy Modules ASHA Health Care Economics Committee saw need for an introduction to main elements of speech-language pathology and audiology health care reimbursement Committee developed six modules presented in a PowerPoint format to help explain rudimentary aspects of billing and coding Developed by ASHA s Health Care Economics Committee, Government Relations and Public Policy Board, and School Finance Committee 50 OVERVIEW: ADVOCACY AND SCHOOL FINANCE ASHA Government Relations and Public Policy Board saw a need to educate students and new members on advocating for the professions. ASHA School Finance Committee saw a need to educate students and new members, especially those in school-based practices, on how school funding works and how members can advocate for themselves and their students in the workplace. CODING AND REIMBURSEMENT MODULES DEVELOPED BY ASHA'S HEALTH CARE ECONOMICS COMMITTEE Module One: Current Procedural Terminology (CPT) - Using Codes to Report Your Services (13:47 minutes) Procedural coding codes reported for services rendered Module Two: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9- CM) - Using Codes to Report Patient Diagnoses (15:34 minutes) ICD-9-CM Diagnostic coding codes reported for speech, language, swallowing, hearing and balance disorders 51 CODING AND REIMBURSEMENT MODULES DEVELOPED BY ASHA'S HEALTH CARE ECONOMICS COMMITTEE CODING AND REIMBURSEMENT MODULES DEVELOPED BY ASHA'S HEALTH CARE ECONOMICS COMMITTEE Module Three: Documentation of Speech-Language Pathology Services in Different Settings (16:52 minutes) Speech-language pathology documentation requirements Module Four: Documentation of Audiology Services in Different Settings (14:12 minutes) Audiology documentation requirements Module Five: Application Module for Speech-Language Pathology (20:07 minutes) Applications of coding and documentation related to speech-language pathology Module Six: Application Module for Audiology (18:58 minutes) Applications of coding and documentation related to audiology
ADVOCACY MODULES PROGRAM OUTCOMES Module Seven: Advocating for Our Professions (15:10 minutes) Developed by ASHA's Government Relations and Public Policy Board Advocating for the professions Module Eight: Advocacy and School Finance (11:49 minutes) Developed by ASHA's School Finance Committee Advocacy and school finance Students who view the entire Coding, Reimbursement, and Advocacy modules program will be able to: Identify the appropriate codes from which to select procedure codes Identify the appropriate codes from which to select diagnostic codes Describe documentation requirements for either audiology or speechlanguage pathology procedures Describe the legislative and regulatory process and be prepared to participate in advocacy for the professions Describe the funding process for schools 56 EDUCATION MODULES RESOURCES http://www.asha.org/practice/reimbursement/modules Need to expose students to coding, billing, advocacy issues within and across academic and clinical coursework Each of the modules include resources for the student available on ASHA s Web site Billing and Reimbursement: www.asha.org/practice/reimbursement Advocacy: www.asha.org/advocacy School Funding Advocacy: www.asha.org/advocacy/schoolfundadv The modules themselves may become a resource we hope you find the program useful 58 QUESTIONS