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2014 R EIMBURSEMENT U PDATE I MPACT ON EDUCATION AND CLINICAL PRACTICE FOR COMMUNICATION S CIENCES AND D ISORDERS - P ART ONE Dee Adams Nikjeh, Ph.D.,

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Presentation on theme: "2014 R EIMBURSEMENT U PDATE I MPACT ON EDUCATION AND CLINICAL PRACTICE FOR COMMUNICATION S CIENCES AND D ISORDERS - P ART ONE Dee Adams Nikjeh, Ph.D.,"— Presentation transcript:

1 2014 R EIMBURSEMENT U PDATE I MPACT ON EDUCATION AND CLINICAL PRACTICE FOR COMMUNICATION S CIENCES AND D ISORDERS - P ART ONE Dee Adams Nikjeh, Ph.D., CCC-SLP Annual CAPCSD Conference April 10, 2014 1

2 D ISCLOSURES Dee Nikjeh has financial relationships to disclose Mileage and one-night’s stay are covered for this presentation She is a paid consultant for the U.S. Department of Justice to investigate Medicare fraud Dee Nikjeh has nonfinancial relationships to disclose She is Co-Chair of ASHA’s Health Care Economics Committee She is advisor to the American Medical Association’s Relative Value Update Committee/Health Care Professionals Advisory Committee 2

3 A GENDA Two Health Care Coding Systems Which is what? (CPT and ICD) What are the principles of coding? 2014 Medicare Physician Fee Schedule How do procedures get a value and a fee? What factors in 2014 will affect fee payment? Four New SLP Evaluation Procedure codes How do we use modifiers and edits appropriately for these new procedures? How are these procedures used in place of CPT 92506? Professional Work What defines skilled care? What is S.M.A.R.T. documentation? 3

4 T WO H EALTH C ARE C ODING S YSTEMS Understanding the coding systems is essential in any discussion of reimbursement and coding. 4

5 T WO H EALTH C ARE C ODING S YSTEMS Procedural Codes – Describe what we DO with the client/patient Current Procedural Terminology, a.k.a. CPT codes Diagnostic Codes – Describe the REASON we are evaluating or treating the client/patient International Classification of Diseases, 9th Revision, Clinical Modification, a.k.a. ICD-9 codes 5

6 I NTERNATIONAL C LASSIFICATION OF D ISEASES, N INTH R EVISION, C LINICAL M ODIFICATION (ICD-9-CM) ICD-10 POSTPONED…AGAIN… 6

7 I NTERNATIONAL C LASSIFICATION OF D ISEASES, 9 TH R EVISION, C LINICAL M ODIFICATION (ICD-9-CM) Numeric classification system of diseases and disorders Chapters are based primarily on body systems (e.g., circulatory, respiratory, nervous) Code or codes to describe the problem or reason for our procedure Issued by the U.S. Department of Health and Human Services Approximately 15,000 codes 7

8 R ESOURCES ICD-9-CM Codes for SLPs: www.asha.org/practice/reimbursement/coding/icd9 SLP.htm www.asha.org/practice/reimbursement/coding/icd9 SLP.htm Guidelines for Coding & Reporting ICD-9-CM: www.cdc.gov/nchs/data/icd9/icdguide.pdf www.cdc.gov/nchs/data/icd9/icdguide.pdf ICD Home Page: www.cdc.gov/nchs/icd9.htmwww.cdc.gov/nchs/icd9.htm Questions: e-mail reimbursement@asha.orgreimbursement@asha.org 8

9 ICD-10-CM B EGINS O CTOBER 1, 2015 ICD-10 includes approx 160,000  ICD-10-CM diagnosis codes for all settings (> 68,000)  ICD-10-PCS procedure codes for hospital inpatients Greater specificity  3-7 alphanumeric characters instead of 3-5 digits (ICD-9-CM) Code descriptors have more detail, less room for error Combination codes represent disease & systems Clearer instructions than ICD-9-CM Accommodate current, complex, and future health care needs 9

10 I NTERNATIONAL CLASSIFICATION OF D ISEASES - C LINICAL M ODIFICATION (ICD-CM) Purpose Standardize disease and procedure classification throughout the US Gather data about basic health statistics and trends Code and classify mortality data from death certificates Clinical Modification – Developed by Center for Disease Control and Prevention (CDC) Owned by the World Health Organization (WHO) 10

11 P RINCIPLES OF ICD C ODING Code to the highest degree of medical certainty or specificity Avoid Not Otherwise Specified (NOS) and Not Elsewhere Classified (NEC)Codes Primary diagnosis is condition (disease, symptom, injury) chiefly responsible for visit or reason for encounter Secondary diagnoses is co-existing conditions or symptoms, or condition found after study If results of diagnostic testing are NORMAL, code signs or symptoms to report the reason for test/procedure and explain normal result in report The procedure (CPT code) should be appropriate for the condition or reason (ICD code) for encounter 11

12 ICD-9 TO ICD-10 ASHA M APPING T OOLS 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 A list of SLP and AUD ICD-10 codes, much like the current ICD-9 list on the ASHA website Products are free and tailored for speech-language pathology and audiology 12

13 ASHA ICD-9 TO ICD-10 M APPING T OOL 13 315.93

14 ASHA ICD-10 M APPING T OOL 14

15 E XAMPLES OF ICD-10-CM FOR SLP F80.1 Expressive language disorder F80.81 Childhood onset fluency disorder F80.4 Speech and language development delay due to hearing loss I69.020 Aphasia following nontraumatic subarachnoid hemorrhage I69.120 Aphasia following nontraumatic intracerebral hemorrhage I69.320 Aphasia following cerebral infarction R13.11 Dysphagia, oral phase R41.841 Cognitive communication deficit R48.8 Other symbolic dysfunctions R49.21 Hypernasality 15

16 ICD-10: Q UESTIONS FOR CMS Will Oct. 1, 2015, become the new deadline? Will the agency allow organizations that are ready to implement ICD-10 to do so voluntarily? Will agency scrap ICD-10 altogether and instead, wait for ICD-11 which is due to e released in 2017? 16

17 RESOURCES ICD-10-CM ASHA Website for ICD-10 www.asha.org/Practice/reimbursement/coding/ICD- 10/ www.asha.org/Practice/reimbursement/coding/ICD- 10/ ICD-9 to ICD-10 ASHA Mapping Tool www.asha.org/icdmapping.aspx www.asha.org/icdmapping.aspx National Center for Health Statistics Website: www.cdc.gov/nchs/icd/icd10cm.htm www.cdc.gov/nchs/icd/icd10cm.htm Centers for Medicare & Medicaid Services Website: www.cms.gov/ICD10/ www.cms.gov/ICD10/ 17

18 2014 CPT “… a set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other health care providers.” 18

19 C URRENT P ROCEDURAL T ERMINOLOGY AKA CPT C ODES 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 19

20 R ELATIVE V ALUE U NIT (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 3 components make up a relative value Professional work Practice expense Professional liability insurance All procedures are ranked on this same scale Standardized physician payment schedule 20

21 M EDICARE I MPROVEMENTS FOR P ATIENTS AND P ROVIDERS A CT OF 2008 (MIPPA) MIPPA – Effective July 1, 2009 Granted SLPs independent billing to Medicare Changed our status with CMS to a Medicare Provider Recognized SLPs as professionals rather than technical assistants Allowed for the “relative value” of SLP CPT (procedure) codes to be re-valued to include a professional work component 21

22 22 T HREE C OMPONENTS OF R ELATIVE V ALUE U NIT *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

23 2014 M EDICARE P HYSICIAN F EE S CHEDULE Extended through March 31, 2015 23

24 M EDICARE P HYSICIAN F EE S CHEDULE RVU X Monetary Conversion Factor = Medicare Payment per Procedure Payment adjusted for geographic location Conversion Factor for 2013 = $34.0376 Conversion Factor for 2014 = $35.8228 0.5% increase Pathway for SGR Reform Act of 2013 – Law 12-26-13 24

25 www.asha.org/practice/reimbursement/medicare/feeschedule/ 25

26 F ACTORS A FFECTING P AYMENT S CHEDULE Conversion Factor Sustainable Growth Rate (SGR) Therapy Cap and Medical Manual Review Sequestration Multiple Payment Procedure Reduction Geographic location 26

27 C ONVERSION F ACTOR - W HAT ’ S T HAT ? … OR W HAT W AS T HAT ? CF based on the Medicare Sustainable Growth Rate (SGR) SGR enacted by the Balanced Budget Act of 1997 Method used by CMS to control Medicare spending by physician services CF recommended to Congress by CMS CF changes payments for physician services for the next year in order to match the targeted SGR If expenditures for previous year exceeded targeted expenditures, then conversion factor decreased payments for the next year and vice versa Despite CMS recommendations for major cuts to the CF, Congress has not changed CF since 2011 27

28 S USTAINABLE G ROWTH R ATE REPEALED ? REFORMED? REPLACED? March 31, 2014 - 12-month patch Extends current 0.5% update through the end of 2013 Freezes payment rates until March 31, 2015 Extends Therapy Cap Extends Post-payment Manual Medical Review Senate and House agree on Repeal but not on the details Congress has passed 17 such patches over past 11 years 28

29 M ERIT -B ASED I NCENTIVE P AYMENT S YSTEM (MIPS) – L OOKING TO THE F UTURE Incentive payment program that will focus the fee-for-service system on providing value and quality on patient performance Quality measures Resource use Clinical practice improvement activities Electronic Health Record meaningful use May professionals with the opportunity to receive additional payment adjustments through use of this merit-based system Stay tuned…more to come 29

30 M ANUAL M EDICAL R EVIEW OF T HERAPY S ERVICES C ONTINUES A T L EAST U NTIL A PRIL 1, 2015 Therapy cap of $1,920 continues for combined PT and SLP Continue to use the KX modifier at $1,920 limit Exceptions Process – For Medicare Part B therapy services that exceed the $3,700 threshold the post- payment (all states) manual medical review continues Resources Ingrida Lusis, ASHA's director of federal and political advocacy, at ilusis@asha.orgilusis@asha.org Questions related to the therapy cap exceptions process, should be directed to reimbursement@asha.org.reimbursement@asha.org 30

31 M ULTIPLE P ROCEDURE P AYMENT R EDUCTION (MPPR) Reduces practice expense (PE) payment for second and subsequent procedures provided on the same day to the same patient for Medicare Part B services Expanded to therapy services in 2011 50% decrease in PE fees for Part B services in all settings New SLP evaluation procedure codes are included in MPPR 31

32 S EQUESTRATION 2% reduction on the 80% Medicare payment continues No end in sight for this… 32

33 CPT 92506 E VALUATION OF SPEECH, LANGUAGE, VOICE, FLUENCY, COMMUNICATION AND / OR AUDITORY PROCESSING “Please describe the typical patient and explain to us exactly what you do for procedure 92506.” 33

34 F OUR N EW SLP E VALUATION P ROCEDURE C ODES R EPLACE CPT 92506 J ANUARY 1, 2014 92521 - Evaluation of speech fluency (e.g., stuttering, cluttering) 92522 - Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) 92523 - Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) with evaluation of language comprehension and expression (e.g., receptive and expressive language) 92524 - Behavioral and qualitative analysis of voice and resonance 34

35 CPT 92521 - E VALUATION OF SPEECH FLUENCY ( E. G., STUTTERING, CLUTTERING ) Vignette for CPT 92521 A 7-year-old male presents with stuttering that includes behavioral (e.g., repetitions, prolongations, and blocks) and affective (e.g., avoidance and/or reduction of communication interaction) responses that negatively impact his communication function. 35

36 CPT 92522 - E VALUATION OF SPEECH SOUND PRODUCTION ( E. G., ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA ) Vignette for CPT 92522 A 6-year-old male presents with age-appropriate language comprehension and expression; yet, his speech sound production is unintelligible and negatively impacts his abilities to successfully communicate with others. 36

37 CPT 92523 - E VALUATION OF SPEECH SOUND PRODUCTION ( E. G., ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA ) WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION ( E. G., RECEPTIVE AND EXPRESSIVE LANGUAGE ) Vignette for CPT 92523 A 5-year-old male presents with significant deficits of receptive, expressive, and social language and highly unintelligible speech sound production that limit his abilities to understand and communicate effectively in daily social and educational activities with family and peers. 37

38 CPT 92524 - B EHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE Vignette for CPT 92524 A 38 year-old female diagnosed with bilateral vocal cord nodules was referred for an evaluation of functional voice use and resonance to facilitate the design of a voice therapy/behavioral treatment plan. The patient complains of progressive hoarseness, inadequate projection, altered resonance, vocal fatigue, and tightness and pain in her throat which compromises her ability to communicate effectively. 38

39 W HY IS THERE NOT A LANGUAGE - ONLY EVALUATION PROCEDURE CODE ? Language-only evaluation for children is rare in the absence of speech sound production Survey of practices/clinics confirmed that this occurs less than 20% of the time However, speech-sound production commonly evaluated in absence of language testing If two or more procedures are billed together greater than 51% of the time, CMS considers them to overlap and will bundle the procedures and decrease the reimbursement If evaluating only language, may code 92523 with the -52 modifier* indicating reduced service Keep in mind SLPs have evaluation procedure codes for standardized cognitive assessment, developmental assessment, and aphasia 39

40 B ILLING C ODES T OGETHER ? Sometimes it is appropriate for more than one disorder to be evaluated on the same day or for more than one procedure to be billed on the same day Documentation should clearly reflect a complete and distinct evaluation for each disorder Evaluation codes should not be billed for brief assessments that could be considered screenings Time for identification of other disorders is already built into the value of each code Inappropriate use of multiple evaluations on same day will result in restrictions through the National Correct Coding Initiative (CCI) edits 40

41 E DITS AND M ODIFIERS Coding Clarification 41

42 C ODING C LARIFICATIONS - E DITS οTwo types of similar edit systems depending on setting οNational Correct Coding Initiative (CCI) – any Part B services not rendered in a hospital οOutpatient Code Editor (OCE) – outpatient hospital services οAutomated edit systems used by CMS to control specific CPT code pairs that can be reported on the same day for the same patient οCCI is updated quarterly and OCE follows one quarter later οSince late 2010, CCI also applies to Medicaid per federal law 42

43 C ODING C LARIFICATIONS -E DITS Some procedures considered to be “mutually exclusive” and may not be billed together for the same patient on the same day Examples for SLP 92607 (Speech-generating device evaluation) & 92597 (Voice prosthetic evaluation) 92507 (Speech, lang tx) & 97532 (Cog tx) 92522 (Speech eval) & 92523 (Speech & Lang eval) SLP CCI Edits can be found at www.asha.org/practice/reimbursement/coding/CCI_edits _SLP.htm www.asha.org/practice/reimbursement/coding/CCI_edits _SLP.htm 43

44 M EDICALLY U NLIKELY E DITS (MUE S ) 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 92507 1speech tx 925261dysphagia tx 961053aphasia assessment per hour 961252cognitive performance testing per hour For a complete list of SLP-related MUEs, see: www.asha.org/Practice/reimbursement/coding/Medi cally-Unlikely-Edits-SLP/ www.asha.org/Practice/reimbursement/coding/Medi cally-Unlikely-Edits-SLP/ 44

45 C ODING C LARIFICATION S PECIAL C IRCUMSTANCES - M ODIFIERS -59 Indicates Distinct Procedural Service Only modifier used with NCCI edits For two procedures not ordinarily performed on the same day by the 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) Who provides the service GN: Speech-language pathologist GO: Occupational therapist GP: Physical therapist Severity Level Modifiers with G-codes for functional claims reporting 45

46 E XAMPLES OF M ODIFIERS S OMETIMES USED BY SLP S “-52” indicates an abbreviated procedure “-59” indicates that two procedures are distinct and separate CPT 92611 (MBS) & 92610 (Clinical Swallow Eval) CPT 92526 (Dysphagia tx) & 97532 (Cog tx) CPT 92508 (Group tx) & 92507 (Indiv tx) CPT 96105 (Aphasia assessment) & 96125 (Cognitive Performance testing) “-22” indicates a much longer than usual procedure “-76” indicates a repeat procedure by the same provider on the same date of service 46

47 ASHA CCI E DIT P AGE FOR SLP C ODES 47 www.asha.org/practice/reimbursement/coding/CCI_edits_SLP.htm

48 ASHA R ESOURCES ᴏManual Medical Review ᴏwww.asha.org/Practice/reimbursement/ExceptionProcess/www.asha.org/Practice/reimbursement/ExceptionProcess/ ᴏMedicare Physician Fee Schedule ᴏwww.asha.org/practice/reimbursement/medicare/feeschedule/www.asha.org/practice/reimbursement/medicare/feeschedule/ ᴏNational Correct Coding Initiative (CCI Edits) ᴏwww.asha.org/practice/reimbursement/coding/CCI_edits_SLP.htmwww.asha.org/practice/reimbursement/coding/CCI_edits_SLP.htm ᴏMedically Unlikely Edits (MUEs) ᴏwww.asha.org/Practice/reimbursement/coding/Medically-Unlikely- Edits-SLP/www.asha.org/Practice/reimbursement/coding/Medically-Unlikely- Edits-SLP/ 48

49 N EW SLP E VALUATION C ODES Q UESTIONS AND A NSWERS CPT 92521 CPT 92522 CPT 92523 CPT 92524 49

50 S CENARIO 1: SLP CPT Q UESTION May I bill CPT 92522 and 92523 together on the same day? CPT 92522 - Evaluation of Speech-sound production (e.g., articulation, phonological process, apraxia, dysarthria) CPT 92523 - Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) with evaluation of language comprehension and expression (e.g., receptive and expressive language) 50

51 S CENARIO 1: SLP CPT A NSWER No, do NOT Code these two together, only one or the other CPT 92523 INCLUDES the evaluation of speech sound production 51

52 S CENARIO 2: SLP CPT Q UESTION When I evaluate a child who has a cleft palate and speech and language problems, what procedures may I code? 52

53 S CENARIO 2: SLP CPT A NSWER CPT 92523 Speech-sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language) CPT 92524 Behavioral and qualitative analysis of voice and resonance 53

54 S CENARIO 3: SLP CPT Q UESTION I evaluate an adult with a voice disorder, using the new procedure code CPT 92524 (Qualitative and behavioral analysis of voice and resonance). Patient has no resonance disorder. Do I code CPT 92524 with -52 modifier to indicate a shortened evaluation? 54

55 S CENARIO 3: SLP CPT A NSWER -52 modifier is not required if only voice or only resonance is evaluated Descriptor of CPT 92524 is written so that voice and/or resonance may be evaluated Recommend a statement of observation that one or the other is not impaired Code developed so that those who work with cleft palate have appropriate choices of procedure codes 55

56 S CENARIO 4: SLP CPT Q UESTION I am evaluating a patient who has Parkinson’s disease. He has dysarthria and a voice impairment. May I do more than one evaluation procedures and which procedures codes may I use? 56

57 S CENARIO 4: SLP CPT A NSWER YES CPT 92522 Speech-sound production(e.g., articulation, phonological process, apraxia, dysarthria) CPT 92524 Qualitative and behavioral analysis of voice and resonance Document completely including your recommendations for plan of care based on your two evaluations 57

58 S CENARIO 5: SLP CPT Q UESTION I am evaluating a patient who is referred because of cognitive impairment. I used to code CPT 92506. What should I do now? 58

59 S CENARIO 5: SLP CPT A NSWER You may use CPT 96125 (Standardized cognitive performance testing, per hour) for evaluation of cognitive skills and abilities CPT 96125 is a per hour code which requires at least 31 mins for one hour or 91 to 151 mins for two hours of billing. This includes administration and documentation. Standardized and nonstandardized subtests may be included in the battery of measurement tools. Cognitive assessment using informal tools and lasting less than the 31 mins may be considered a screening and payment may be denied. For language only, possible to code 92523 with -52 modifier. Caution: Value for shortened procedure has not been established. 59

60 S CENARIO 6: SLP CPT Q UESTION What if I provide both a cognitive assessment AND a speech sound production with language evaluation? How do I code this? 60

61 S CENARIO 6: SLP CPT A NSWER Few circumstances (e.g., child with language-learning disorder) may warrant both complete cognitive evaluation (CPT 96125) and evaluation of speech-sound production with receptive and expressive language (CPT 92523). If you complete both a full cognitive evaluation and a comprehensive speech & language evaluation, you may bill CPT 96125 AND 92523 with -59 modifier on 96125 Documentation must show separate and distinct procedures Combine with CAUTION; Cognitive treatment (97532) and speech and language treatment (92507) may NOT be billed together on the same day to same patient b/c of overlap 61

62 S CENARIO 7: SLP CPT Q UESTION What if it takes two visits to complete CPT 92523 (speech sound production with language evaluation) and then 45 minutes to interpret and complete documentation? Can I bill CPT 92523 for 3 visits? 62

63 S CENARIO 7: SLP CPT A NSWER No, CPT 92523 is not a timed code and may only be billed once. The value of the code includes 120 minutes of intra- service time. Recommend to complete as much of the evaluation as possible on the initial visit and if necessary, complete the additional tests and measures during the subsequent treatment sessions. 63

64 S CENARIO 8: SLP CPT Q UESTION I see a child for a speech fluency evaluation and also perform an oral peripheral examination. Can I bill CPT92521 (Evaluation of speech fluency) and 92522 (Evaluation of speech sound production)? 64

65 S CENARIO 8: SLP CPT A NSWER No. An oral peripheral examination is an integral part of every speech, language, fluency, and voice evaluation and the time spent on the examination of is already built into each evaluation code. 65

66 S CENARIO 9: SLP CPT Q UESTION What do I code for reevaluations? 66

67 S CENARIO 9: SLP CPT A NSWER Because evaluations are provided for children and adults who have communication impairments and much of our testing is standardized to establish basal and ceilings, age norms, percentiles, etc., the reevaluation is just as detailed as the initial evaluation. For that reason, SLPs do not have reduced reimbursement for reevaluations. Document your evaluation findings and compare to previous evaluation 67

68 R E - EVALUATION W HEN I S I T A PPROPRIATE ? A formal re-evaluation is covered if documentation supports need for further tests and measurements after initial evaluation Indications for a re-evaluation New clinical findings, Significant change in the patient's condition, Failure to respond to therapeutic interventions outlined in plan of care. Re-evaluation is focused on Evaluation of progress toward current goals Making a professional judgment about continued care Modifying goals and/or treatment Terminating services Re-evaluation may be appropriate Prior to discharge to determine whether goals have been met For use by physician or treatment setting where treatment will be continued Continuous assessment of patient's progress is a component of ongoing therapy services and not payable as a re-evaluation 220.3 - Documentation Requirements for Therapy Services (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14) 68

69 S CENARIO 10: SLP Q UESTION What do I code if I do a pediatric language-only evaluation? 69

70 S CENARIO 10: SLP A NSWER In the atypical evaluation when only a child’s language is evaluated, SLPs may bill 92523 with the -52 modifier, which is used to indicate a shortened procedure compared to the full description of the service. CAUTION: There is no established value for a shortened procedure CPT 96125 (Standardized cognitive performance testing, per hour) or CPT 96111 (Developmental testing --includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments with interpretation and report) may be appropriate options Recommend including evaluation of speech-sound production 70

71 S CENARIO 11: SLP CPT Q UESTION I am evaluating an adult who has a traumatic brain injury and dysarthria. Which evaluation procedures and CPT codes may I use? 71

72 S CENARIO 11: SLP CPT A NSWER You may code CPT 96125 for cognitive assessment This is a timed, per hour code 31 minutes is allowable for one hour OR You may code CPT 96105 for aphasia assessment This is a timed, per hour code 31 minutes is allowable for one hour If rationale to support both, then put -59 modifier on 96125 You may code CPT 92522 - Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) Document each procedure with results, interpretation, recommendations, etc. 72

73 S CENARIO 11 C ONTINUED : Q UESTION What if that dysarthria has a phonatory component? In addition to the cognitive assessment and the speech-sound production evaluation, may I also add a voice evaluation and maybe also an acoustic and aerodynamic assessment? 73

74 S CENARIO 11 C ONTINUED : A NSWER 74

75 RESOURCES For Medicare, get in touch with the Medicare Administrative Contractor in your area. If you continue to have problems, please contact ASHA's health care economics and advocacy team at reimbursement@asha.org.Medicare Administrative Contractorreimbursement@asha.org Notifications and news items will be available through ASHA Headlines and The ASHA Leader. Specific questions can be directed to ASHA's health care economics and advocacy team at reimbursement@asha.org.ASHA HeadlinesThe ASHA Leaderreimbursement@asha.org 75

76 W HAT IS “S KILLED ” T REATMENT ? W HAT IS “ NONSKILLED ” T REATMENT ? 76

77 M EDICARE I MPROVEMENT S TANDARD C LARIFICATION CMS - “Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage.” Jan 24, 2013 – Federal judge ruled  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 statue specifies “rehabilitative” 77

78 J IMMO V. S EBELIUS S ETTLEMENT A GREEMENT Coverage not dependent on potential for improvement, but rather on the need for skilled care 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 Coverage is not available when the beneficiary’s maintenance care needs can be addressed safely and effectively through the use of nonskilled personnel (e.g., assistants, qualified personnel, caretakers or the patient). See www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdfwww.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf 78

79 P UB 100-02 M EDICARE B ENEFIT P OLICY, T RANSMITTAL 179 D ATE : J ANUARY 14, 2014 Skilled maintenance therapy may be covered when Patient’s special medical complications or complexity of the therapy procedures require skilled care An individualized assessment of patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified speech- language pathologist are necessary for the performance of a safe and effective maintenance program to maintain the beneficiary at maximum practicable level of function http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R179BP.p dfhttp://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R179BP.p df 79

80 P ROFESSIONAL S KILLED T REATMENT “For patients with chronic or degenerative conditions, evaluate patient’s current functional performance; provide treatment to optimize current functional ability, prevent deterioration, and/or modify maintenance program” (Medicare Benefit Policy Manual, Chapter 15, Section 220.2 C&D). 80

81 W HAT D OES A P ROFESSIONAL D O ? Practice at the TOP of our license Clinical decision-making – using expert knowledge Develop and modify treatment and maintenance programs Train, instruct and supervise others 81

82 P ROFESSIONAL SKILLED T REATMENT S PECIFICS Analyze medical/behavioral data and select appropriate evaluation tools/protocols to determine communication/swallowing diagnosis and prognosis. Design plan of care (POC) including length of treatment; establishment of long- and short-term measurable, functional goals and discharge criteria. Develop and deliver treatment activities that follow a hierarchy of complexity to achieve the target skills for a functional goal. http://www.asha.org/Practice/reimbursement/me dicare/Documentation-of-Skilled-Versus- Unskilled-Care-for-Medicare-Beneficiaries/ 82

83 P ROFESSIONAL SKILLED T REATMENT Based on expert observation, modify activities during treatment sessions to maintain patient motivation and facilitate success. Increase or decrease complexity of treatment task. Increase or decrease amount or type of cuing needed. Increase or decrease criteria for successful performance (accuracy, number of repetitions, response latency, etc.). Introduce new tasks to evaluate patient’s ability to generalize skill Conduct ongoing assessment of patient response in order to modify intervention based on: patient performance in treatment activities; patient report of functional limitations and/or progress 83

84 P ROFESSIONAL SKILLED T REATMENT Engage patients in practicing behaviors while explaining the rationale and expected results and/or providing reinforcement to help establish a new behavior or strengthen an emerging or inconsistently performed one Develop maintenance program—to be carried out by patient and caregiver—to ensure optimal performance of trained skills and/or to generalize use of skills Train patients/caregivers in use of compensatory skills and strategies (e.g., feeding and swallowing strategies, cognitive strategies for memory and executive function) 84

85 O UTPATIENT S CENARIO : PATIENT CURRENTLY NOT RECEIVING THERAPY UNDER A THERAPY PLAN OF CARE Patient with multiple sclerosis needs maintenance program to slow or prevent deterioration in communication ability caused by medical condition Therapy services from qualified SLP may be covered to establish maintenance program even though patient’s current medical condition does not yet justify need for individual skilled therapy sessions Evaluation, establishment of the program, and training family or support personnel may require the skills of a therapist and would be covered NOTE: In this example, the skills of a therapist are not required to actually carry out the maintenance program services and, as a result, are not covered. 85

86 W HAT IS U NSKILLED C ARE ? 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 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 86

87 W HAT IS U NSKILLED C ARE ? 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 Ref: Pub 100-02 Medicare Benefit Policy, Transmittal 179 87

88 M EDICARE R ULE - U SE OF SLP A SSISTANTS Services of SLP Assistants NOT recognized for Medicare coverage Therapy services provided by SLP Assistants, even if they are licensed to provide services in their states, will be considered unskilled services and denied as not reasonable and necessary Check state law for what assistants can and cannot do in what settings (e.g., schools vs. health care) Ref: Medicare Benefit Policy Manual, Ch15, 230.3 - Practice of Speech- Language Pathology, (Rev. 106, Issued: 04-24-09, Effective: 07-01-09, Implementation: 07-06-09) 88

89 M EDICARE R ULE - U SE OF SLP S TUDENTS Medicare requires 100% personal supervision of SLP students by qualified SLP in outpatient setting Must be in the room directing the service Must not be engaged in other activities Student considered extension of qualified practitioner Qualified* SLP (for Medicare) meets one of the following requirements: The education and experience requirements for Certificate of Clinical Competence in SLP granted by ASHA; or Meets educational requirements for certification and is in process of accumulating the supervised experience required for certification. Only services of qualified practitioner can be billed and paid This does NOT apply to non-Medicare settings unless specified * qualified not always same definition for Medicaid 89

90 D OCUMENTATION How do you document to show skilled services? 90

91 D OCUMENTATION SMART goals Specific Measurable Actionable/Attainable Relevant/ Realistic Time-bound Focus on practical function Treatment notes and Progress Reports need to be patient/client-specific and relevant Ref for history of SMART goals: Doran, George T. “There’s a S.M.A.R.T. way to write management’s goals and objectives.” Management Review 70.11 (Nov. 1981): 35.Business Source Corporate. EBSCO. 15 Oct. 2008.EBSCO 91

92 D OCUMENTATION - F UNCTIONAL G OAL W RITING Long Term Goals – Developed for entire episode of care Measureable and specific to the identified functional impairment When episode is anticipated to be longer than one certification period (90 days), LTG may be specific to current certification period Short Term Goals – Developed for week or month of therapy Help to track progress toward LTG for episode of care The “what” and “why” Treatment Objectives Treatment strategies and activities The “how” 92

93 D OCUMENTATION - R EFLECT T HE VALUE OF SLP C ARE Descriptions and rationale of skilled treatment intervention strategies Changes made to treatment due to assessment of patient’s needs on a particular treatment day Modification of treatment tasks and rationale due to patient’s progress or regression Reasons for lack of progress and the justification for continued treatment if treatment continues after regression or plateau 93

94 D OCUMENTATION – W HAT NOT TO W RITE Vague or subjective descriptions of the patient’s care Terminology that would not adequately describe the need for skilled care: Continue with POC Patient tolerated treatment well Patient remains stable Such phraseology does not provide a clear picture of the results of treatment, nor “next steps” that are planned. 94

95 I F IT WAS NOT DOCUMENTED, IT WAS NOT DONE ! Documentation serves as the means by which a provider may establish and a Medicare contractor or auditor may confirm that skilled care is, in fact, needed and received 95

96 RESOURCES http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R1 79BP.pdfhttp://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/Downloads/R1 79BP.pdf www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/SNFPPS/Downloads/Jimmo- FactSheet.pdf 96

97 ASHA RESOURCES S KILLED V ERSUS U NSKILLED T REATMENT “Documentation of Skilled Versus Unskilled Care for Medicare Beneficiaries” http://www.asha.org/Practice/reimburseme nt/medicare/Documentation-of-Skilled-Versus- Unskilled-Care-for-Medicare-Beneficiaries/ “Examples of Documentation of Skilled and Unskilled Care for Medicare Beneficiaries” http://www.asha.org/Practice/reimburseme nt/medicare/Examples-of-Documentation-of- Skilled-and-Unskilled-Care-for-Medicare- Beneficiaries/ 97

98 2014 CAPCSD A NNUAL M EETING 98

99 THANK YOU VERY MUCH! 99 After Lunch – Part Two: Reimbursement Update with Dr. Bob Fifer


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