Medicare 101 Lisa Satterfield, ASHA director, health care regulatory advocacy Neela Swanson, ASHA director, health care coding policy
Neela Swanson Director, Health Care Coding Policy, ASHA Disclosure Financial ASHA employee Nonfinancial Contributor to multiple for-sale ASHA products on the topics of health plan payments, coding, and payer advocacy; receives no compensation for product sales 2
Lisa Satterfield, MS, CCC-A Director, Health Care Regulatory Advocacy, ASHA Disclosure Financial ASHA employee Nonfinancial Contributor to multiple for-sale ASHA products on the topics of health plan payments, coding, and payer advocacy; receives no compensation for product sales 3
Agenda Medicare Basics Medicare Part A Medicare Part B Documentation Coding and Billing Near Future Medicare
Foundational Rules Understanding the patients and the providers of Medicare services
Medicare Patients Age 65 or older US citizen or permanent resident Person or spouse has 40 credits of Social Security (appx 10 years) Government employee Under 65 Entitled to Social Security disability at least 24 months ALS Permanent kidney failure requiring dialysis
Medicare Providers Licensed or registered in the state Have completed the required degree in the related field Master s for SLPs and audiologists prior to 2007 AuD for audiologists after 2007 Registered for National Provider Identifier (NPI)
NPI First step for billing ANY insurance Required by federal law (HIPAA) for providers healthcare services Completed online in 10-20 minutes https://nppes.cms.hhs.gov/nppes/
Enroll in Medicare Medicare requires audiologists and SLPs who provide services Medicare patients to be enrolled! It is against federal law to bill any Medicare patient privately NPI is NOT Medicare enrollment Enroll online at https://pecos.cms.hhs.gov You will need to coordinate with employers
Medicare Benefits Medicare Part A Hospital Insurance Automatic benefit No monthly premium (if minimum Medicare employment is met) Medicare Part B Supplemental for outpatient services Optional benefit Monthly premium 20% co-pay for services Medicare Part C Medicare Advantage Medicare benefits managed by private insurance company Requires enrollment Plans vary by company Medicare Part D Prescription Drug benefit
Medicare Part A Hospitals, Skilled Nursing Facilities, Home Health
Prospective Payment Systems (PPS) Bundled payment systems based on patient severity and projected costs Includes inpatient costs and services provided while in a qualified stay Different systems and calculation methodologies based on the facility type
Hospital Acute Care Inpatient Patient must be officially admitted by a physician Audiology and SLP services included in any daily rate Patients not formally admitted may be under Observation Status: This means they are considered outpatients!!!
Long-Term Care Hospital (LTCH) Average length of stay is greater than 25 days Typically clinically complex, less stable Head trauma Cancer treatment Pain management Payment is under daily rate, similar to acute inpatient
Inpatient Rehabilitation Facility (IRF) Intensive rehab services for complex patients Requires Active and ongoing intervention for multiple therapies one must be PT or OT 3 hours a therapy a day 5 days a week Rehabilitation physician face-to-face visits 3 days a week Tracking is completed through the IRF-PAI
Skilled Nursing Facilities (SNF) Qualifying inpatient hospital stay of at least 3 days Transferred to the SNF within 30 days of discharge from the qualifying stay Required skilled care (nursing and/or therapy) on a daily basis Treatment must be for a condition treated in the inpatient hospital stay or acquired in the SNF Tracking is completed through Minimum Data Set (MDS)
Home Health 60-day episodes that cover Skilled nursing Home health aid PT, OT, SLP Medical social services Excludes equipment If a patient is under a Home Health payment, services cannot be billed separately.
Medicare Part B Fee-For-Service
Fee-For-Services Individual services are paid using Current Procedural Terminology Codes Encourages high volume paid more for the more provided Includes services performed in Private/Group practice University clinics Outpatient skilled nursing Outpatient hospital clinics (therapy services only)* * Outpatient audiology services in hospitals are paid via the Outpatient Prospective Payment System.
Codes Back to the Basics Procedure codes Current Procedural Terminology (CPT) Managed by the American Medical Association Used by all insurers Device codes Healthcare Common Procedure Coding System (HCPCS) Managed by the Centers for Medicare and Medicaid Services (CMS) Includes devices, prosthetics, hearing aids, temporary codes, and few procedures Diagnosis codes - International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Managed internationally by the World Health Organization Clinical Modification (CM) managed by CMS and the National Center for Health Statistics (NCHS)
CPT Codes http://www.asha.org/practice/reimbursement/medicare/feesc hedule/ Audiology Procedures 92540 (vestibular test bundled) 92543 (caloric testing) 92557 (audiometric testing) 92567 (tympanometry) 92585 (ABR) 92587 (OAE) 92601 (Cochlear implant programming) 92625 (Tinnitus eval) 92626 (Aural Rehab eval) SLP Procedure 92507 (SLP treatment) 92521 (Fluency eval) 92522 (Motor speech eval) 92523 (Speech & Lang eval) 92524 (Voice eval) 92610 (Swallowing eval) 96105 (Aphasia eval) 96125 (Cognitive eval) 97532 (Cognitive treatment)
HCPCS Codes Audiology Devices Cochlear Implants L8614 L8629 Osseointegrated Implants L8690 L8699 Hearing Aids V5030 V5298 SLP Devices Tracheostoma supplies A7503 A7509 Speech-Generating Devices E2500 E2599 Artificial larynx, TEP, Voice amplifier L8500 L8515
While we re talking about coding ICD-10 started October 1, 2015. Used by all providers in every health care setting Used by all/most? payers: Medicare, Medicaid, and commercial payers. Significantly expands selection of codes ASHA s ICD-10 website includes: 1. ICD-9 to ICD-10 Mapping Tool 2. ICD-9 to ICD-10 Mapping Spreadsheets 3. ICD-10-CM Code Lists www.asha.org/practice/re imbursement/coding/icd -10/
Medicare Part B Rules Audiology Recognized in Medicare for hearing and balance diagnostic services only Must have physician order prior to testing for coverage Testing must be to diagnosis a conditions or due to new symptoms Hearing aids are not covered Speech-Language Pathology Under the rehabilitation benefit with PT and OT Requires a plan of care signed by a physician Therapy services must be medically indicated and require the skills of a professional The broad definition allows coverage in theory of most services
Therapy Cap is a misnomer Cap on SLP and PT services combined Amount updated annually. HOWEVER exceptions process allows above cap Only requires KX modifier on the claim attesting that the services provided meet Medicare requirements of medical necessity Skilled services are needed for the improvement, maintenance, or the prevention of deterioration of a condition. Therapy cap cannot be used as a reason to stop services or bill the patient directly
Therapy Functional Reporting Requirements Congress requires Medicare to collect functional data on the claim form G-codes with severity modifiers for current status, projected goal, discharge status Swallowing Motor speech Spoken language comprehension Spoken language expression Attention Memory Voice
Physician Quality Reporting System Quality reporting system for audiologists and SLPs to avoid deductions applied to all claims 2016 Measures include Recording medication in the medical record Smoking cessation counseling Pain assessment Screen for depression Falls risk Referral for dizziness
Local Coverage Determinations (LCDs) Medicare Administrative Contractors (MACs) delineate policies regionally 12 geographic regions, 8 contractors LCDs define the CPT codes/icd-10 codes used in the claims processing systems Every region is a little bit different www.asha.org/practice/reimbursement/medicare/medicare- Administrative-Contractor-Resources/
Medicare Documentation
Why document? Audits Medicare Administrative Contractors (MACs) Recovery Audit Contractors (RACs) Office of the Inspector General The services that are billed must be justified The services must meet coverage requirements Skilled services necessary to improvement, maintain, or prevent the deterioration of a condition Identification of a condition to inform a plan of care
Evaluation documentation Physician order Reason for the test Qualifications of the provider Justification of the procedures billed Recommendations and projected prognosis
SOAP Note Subjective findings Current condition, patient complaints, history Behavioral evaluations Objective findings Not influenced by patient input Tympanometry, ABR Instrumental evaluations Assessment Incorporation of the results Plan Recommendations and prognosis
Therapy Plan of Care Diagnosis or diagnoses Long-term goals Functional (G-code) reporting Type, amount, frequency, duration of therapy Certification - dated signature of physician within 30 days of the patient s first visit Recertification (signed by physician) every 90 days
Daily Note Justifies the billing code for the date of service Date of service Procedure(s) performed The amount of time for each procedure Signature and professional identification of provider
Therapy Progress Report/Discharge Note Required every 10 th treatment day Assessment of improvement/progress towards goals Continued treatment or treatment plan revisions Any changes to long or short term goals Functional (G-code) reporting Distinction between rehabilitative therapy and maintenance therapy
Rehab or Maintenance? Rehab = potential to improve Reasonable expectations that improvement is attainable Maintenance = prevent or slow deterioration of a functional status To be billed to Medicare, the services requires skills of a professional for the safty and effective deliverty Services that can be performed by caregiver/unskilled personnel are not covered
Documenting Skilled Services Select appropriate tools and explain logic for that particular selection Explain conclusions/recommendations using professional language and/or technical terminology Document patient engagement, education and counseling Include ongoing assessment and clinical judgement For maintenance, distinguish between the skilled services and the unskilled exercises that will be performed by the patient.
Medicare Supervision Requirments Students and CFs
Levels of supervision General Physician s overall management of the patient Direct Physician is immediately available ; on campus Personal Supervisor is in the room, fully engaged, while procedures are performed Audiologists and SLPs can only provide personal supervision in the Medicare program
Incident to Physician Places responsibility of the service on the physician Integral, though incidental, to physician services Commonly furnished in a office setting Provided under direct supervision of a physician Hearing and balance services provided by audiologists are prohibited from incident to billing: the audiologist must enroll Speech services may be performed incident to however there is no financial advantage, and the physician must be in the office at the time the service is performed
Medicare Rules: Supervision Students require personal supervision 4 th AuD students without a Master s degree and license require personal supervision Clinical Fellows without state issued licensure/certification/registration require personal supervision Colorado, Connecticut, DC, Hawaii, Massachusetts, New York, Pennsylvania??Nevada, North Dakota, Virginia
Personal Supervision Only skilled services of a licensed professional may be billed to Medicare Professional must be in the room directing the session with the student/cf Takes on full responsibility of the services provided Services must be equivalent to those performed by a skilled, licensed professional
Supervision in Skilled Nursing Facilities Student does not have to be in line-of-sight BUT Supervisor cannot be treating another resident for billing of individual therapy If the supervisor is treating another resident, it must be in the same room and it is considered concurrent therapy and should be documented as such
Medicare in the Future Medicare Access and CHIP Reauthorization Act
MACRA Deleted the Sustainable Growth Rate (SGR) formula that caused a potential 25% reduction in Medicare payment every year Established the MIPS program to transition payment from fee-forservice to payment based on quality, outcomes, and efficiency
What does MIPS do? Creates a scoring system to compare and rank providers the same category/discipline Higher performing providers will get bump in payment, lower will receive penalties for 2019, 4 percent for 2020, 5 percent; for 2021, 7 percent; for 2022 and subsequent years, 9 percent. Providers who participate in Alternative Payment Models receive highest composite scores
What does this mean? u Audiologists and SLPs must report quality and outcomes through CMS-approved mechanisms u PQRS u Qualified Clinical Data Registry u Allows professional societies to develop and collect clinically relevant measures, benchmark and risk-adjust the measures u The QCDR must include all payers, not just Medicare u The providers must report on 50% of all of their patients, not just Medicare
Public Reporting and Payment Scores are compared within provider group Audiologists to audiologists/slps to SLPs Composite score 0-100 is given to provider Scores will be published on the Physician Compare website to assist consumer s with provider choices
Look for the Medicare Survivor Guide for purchase product in July, 2016 Register to receive ASHA Headlines www.asha.org/publications/enews/headlines/ Read the Bottom Line articles in the ASHA Leader Keep informed with your state association and your State Advocate for Medicare Policy (StAMP) www.asha.org/practice/reimbursement/medicare/stamp/ What do I do now? Contact ASHA Healthcare Advocacy and Economics Team (HEAT) at: reimbursement@asha.org