Dee Adams Nikjeh, PhD, CCC-SLP

Dee Adams Nikjeh, PhD, CCC-SLP
2016 CAPCSD Conference Reimbursement and Coding For university Speech & Hearing Clinics Part I: Foundation & Structures - Don't Be Intimidated Dee Adams Nikjeh, PhD, CCC-SLP Paul Pessis, AuD Tim Nanof, MSW

Speaker Disclosures Financial Each speaker received complimentary registration for this meeting and air fare Non-Financial Nikjeh: Co-chair ASHA Health Care Economics Committee, Alternate co-chair RUC HCPAC Pessis: Reimbursement and practice management consultant for healthcare providers Nanof: Ex-officio of ASHA’s Health Care Economics Committee

Agenda Part I: Foundation and Structure
Key Health Care Coding Systems International Classification of Diseases -10th Rev HCPCS Level I - Current Procedure Terminology Procedure to Payment 2016 Medicare Physician Fee Schedule for SLP & AUD HCPCS Level II – Equipment, Supplies, Devices Rules and Tools for Coding Efficiency National Correct Coding Initiative Edits Speech-Language Pathology Timed versus Untimed Codes Medically Unlikely Edits Multiple Procedure Payment Reduction Therapy Cap Audiology Physician Referral Medical Necessity Practice Coding Scenarios for Audiology and SLP

Key Health Care Coding Systems
International Classification of Disease, 10th Rev, Clinical Modification Healthcare Common Procedure Coding System – Level I and Level II

Purpose of Coding Systems
Provide common language among providers, third-party payers, and administrators Standardize descriptions of procedures, names of diagnoses, and names of items/supplies Provide data for government to evaluate utilization patterns and appropriateness of health care costs Provide data for health-related research HIPAA mandated code sets: CPT, ICD-10, HCPCS Dee - Nomenclature for speech-language pathology and audiology services varied from facility to facility until codes unified Coding became universal in U.S. when payers, especially Medicare, required them

Healthcare Common Procedure Coding System (HCPCS)
HCPCS Level I a.k.a. Current Procedural Terminology (CPT) Represent what we DO (procedures & services) with the client/patient Owned by American Medical Association HCPCS Level II Based on the American Medical Association's Current Procedural Terminology (CPT) Codes used to report supplies, equipment, and devices

International Classification of Diseases, 10th Revision, Clinical Modification
Diagnostic codes that describe the REASON we are evaluating or treating the client/patient ICD-10-CM effective October 2015

International Classification of Disease, 10th Revision, Clinical Modification
October 1, 2015

ICD-10-CM ICD-10 includes approx 160,000
ICD-10-CM diagnosis codes for all settings > 68,000 codes in Clinical Modification ICD-10-PCS procedure codes for hospital inpatients 21 Chapters based on body systems (e.g. nervous, circulatory, respiratory, digestive) 3-7 alphanumeric characters instead of current 3-5 digits Owned by the World Health Organization (WHO) Required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA) Does NOT affect CPT coding Development of ICD 10 began 1983 and implemented in 1992; US more than 2 decades behind; ICD 10 translated into 43 languages and use in >100 countries; ICD-11 scheduled to be released in 2017;

ICD Coding Principle Highest degree of medical certainty or specificity Carry out to the 7th place (Letters and Numbers) which is the 4th or 5th number when possible. SLP example General = R41.8 Other symptoms and signs involving cognitive functions and awareness More specific = R Frontal lobe and executive function deficit Audiology example General = H90.8 Mixed conductive and sensorineural hearing loss, unspecified sensorineural hearing loss, bilateral More Specific = H90.41 Sensorineural hearing loss, unilateral right ear with unrestricted hearing on the contralateral side From general to specific

ICD Coding Principle When results of diagnostic testing are NORMAL, code signs or symptoms to report the reason for test/procedure and explain normal result in report There is NO ICD code for “normal” There’s no ICD code for “normal”

Official Instructions - How to Code When Results are Normal
For outpatient services, ICD-10-CM guidelines state, “Do not code diagnoses documented as 'probable,' 'suspected,' 'questionable,' 'rule out,' or 'working diagnosis' or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.” For inpatient services (including short-term, acute, and long-term care), ICD-10-CM advises "If the diagnosis documented at the time of discharge is qualified as 'probable,' 'suspected,' 'likely,' 'questionable,' 'possible,' or 'still to be ruled out' or other similar terms indicating uncertainty, code the condition as if it existed or was established.” ICD-10-CM Official Guidelines for Coding and Reporting

ICD Coding Principle Code “other” or “other specified” when information in medical record provides detail for which a specific code does not exist; usually code ends with a 4th digit “8” or 5th digit “9” H91.8X- Other specified hearing loss F Other developmental disorders of speech and language Code “unspecified” codes when information in medical record is insufficient to assign a more specific code; usually code ends with a 4th digit “9” or 5th digit “0” F80.9 Developmental disorder of speech and language, unspecified R49.9 Unspecified voice and resonance disorder R42 Dizziness and giddiness (replaced CPT) excludes vertiginous syndromes, but is used for light-headedness or vertigo not otherwise specified For example - F Other developmental disorders of speech and language that is not described in F80.0

ICD Coding Principle ICD code (reason) and CPT code (procedure) should correspond for encounter. SLP Example ICD R13.11 Dysphagia, oral phase CPT Clinical Swallow Evaluation Audiology Example ICD H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side CPT Comprehensive audiometry threshold evaluation and speech recognition (92553 and combined)

ICD Coding Principle Primary diagnosis - condition (disease, symptom, injury) chiefly responsible for visit or reason for encounter Secondary diagnoses - co-existing conditions or symptoms, or condition found after study Primary R49.21 Hypernasality Secondary Q37.4 Cleft Palate Exceptions - Instructions for “code first,” “use additional code,” or “in diseases classified elsewhere” I Dysphagia following cerebral infarction “use additional code to identify the type of dysphagia, if known” R13.1 Dysphagia “Code first, if applicable, dysphagia following cerebral vascular disease” R47.82 Fluency disorder in conditions classified elsewhere; “Code first underlying disease or condition, such as Parkinsons’s disease (G20)” Coding preferences may also be specific to your work setting or payer Procedures for coding primary and secondary may be specific to the facility or work setting

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

ICD Coding Principle New twist for SLPs…
Due to an Excludes1 note, the R47 family (dysarthria, speech disturbance, etc.) cannot be used in conjunction with the code for Autism (F84.0) ASHA is looking into options to resolve the issue In the meantime, use F80.0 (developmental phonological disorder) with the autism diagnosis

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

NEW ICD-10 Chapter 20 External Causes
External Cause not required at this time for SLP or AUD NEW ICD-10 Chapter 20 External Causes

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

ICD-10-CM Audiology Appropriate codes found in:
Alphabetic Index - alphabetical list by disease OR Tabular List – numeric list of codes divided into 21 chapters according to body system or nature of injury or disease Most Audiology codes are located within the Chapter 8: Diseases of the Ear and Mastoid Process

ICD-10-CM Audiology Laterality and Placeholder
The final digit indicates laterality: 1 is for right; 2 for left; 3 for bilateral; 0 or 9 for unspecified Placeholder character “X”– Some codes have a placeholder in the 6th digit to allow for future expansion

ICD-10 Coding Options H90 Conductive and sensorineural hearing loss
H90.0 Conductive hearing loss, bilateral H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side H90.12 Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side H90.3 Sensorineural hearing loss, bilateral H90.41 Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side H90.42 Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side

Additional Options H90.6 Mixed conductive and sensorineural hearing loss, bilateral H90.71 Mixed conductive and sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side H90.72 Mixed conductive and sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side H90.8 Mixed conductive and sensorineural hearing loss, unspecified

It’s Not All Bad: Being Specific…
H91.21 Sudden idiopathic hearing loss, right ear H83.3X3 Noise effects on inner ear, bilateral H93.11 Tinnitus, right ear H Hyperacusis, right ear H83.02 Labyrinthitis, left ear H91.03 Ototoxic hearing loss, bilateral H TTS, bilateral Third party payers want specificity which needs to be supported with detailed chart documentation

Don’t Worry, Be Happy! Quiz time: What constitutes a proper diagnosis? Hint: three things History Symptoms Findings Currently, there are no codes to represent a different type of hearing loss for EACH ear: (i.e., conductive of the right and sensorineural of the left)

American Academy of Audiology Tools for ICD-10-CM
Available Resources Include: Editable superbill template for CPT, ICD-10, CPT Modifiers, and PQRS Measurement reporting guidelines Comprehensive listing of audiology related ICD-10 codes with descriptor Important links and tools

2016 Current Procedural Terminology
Procedure to Payment 2016 Medicare Physician Fee Schedule for SLP & Aud

Current Procedural Terminology (aka CPT Codes)
Every medical, surgical, and diagnostic procedure assigned a 5-digit code CPT codes are used to Simplify the reporting of services Ensure uniformity of communication Approximately 8,000 codes Developed, maintained, and copyrighted by the American Medical Association (AMA) Updated annually Dee Development and maintenance of these codes is overseen by editorial boards at the AMA, and the publications of all the software, books and manuals needed by those who use them brings millions in income to the AMA each year.

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

Relative Value Unit (RVU)
Every CPT procedure or service has a resource-based relative value Payment for services are determined by the resource costs needed to provide them 3 Components of a relative value unit Professional Work Practice Expense Malpractice Insurance Dee - Give example of RBRVS…primary care office visit, speech therapy session, and neuro surgery are rated in relation to each other and the resources needed to provide the procedure or service Internal note: First RCU meeting Nov 1991; Medicare RBRVS fee schedule implemented Jan 1992 Since 1992, AMA has used this resource-based relative value scale

Relative Value Unit- 3 Components
*Professional Work* Time it takes to perform the service Technical skill and physical effort Required mental effort and judgment Stress due to the potential risk to the patient Practice Expense Time of support personnel** Supplies Equipment Overhead Professional Liability/Insurance Costs Prior to July 1, 2009, SLPS were considered technical support and our value was determined by minutes in the practice expense. Unlike PT and OT who were considered professionals, SLPs were considered support personnel…now considered professional and value is quality of work & outcomes PROFESSIONAL DECISION MAKING SKILLS NOT HOW MANY MINUTES WE SPEND WITH THE PATIENT!

From Relative Value to Dollar Value
Relative Value Units (RVUs) are assigned thru a rigorous procedure developed by the AMA All medical procedures are ranked on the same relative value scale AMA recommendations for RVUs sent to Centers for Medicare and Medicaid (CMS) Accepted, rejected, or adjusted Ranked RVU X Monetary Conversion Factor = Medicare Payment per Procedure Establishes the Medicare Physician Fee Schedule Payment adjusted for geographic location Dee

CPT & RUC Process CPT Editorial Panel AAA and/or ASHA Defend
Negotiate Rationalize AAA and/or ASHA Complete Request Form Collect Data Write Vignettes Collaborate Related Orgs CPT HCPAC Advisors RUC HCPAC Advisors RUC – Relative Value Update Com. Recommend a Relative Value Defend Professional Work Value Professional Liability/Insurance Practice Expense Subcommittee Dee – description of Healthcare Professional Advisory Committee CMS Accept, Reject, Adjust ASHA Advocacy Reimbursement Assigned CPT Code Book Medicare Fee Schedule Approximately 3 Years

Healthcare Professional Advisory Committee Review Board
Non-Physician Representation Members – Audiologists, Speech-Language Pathologists, Chiropractors, Dieticians, Nurses, Occupational Therapists, Optometrists, Physical Therapists, Physician Assistants, Podiatrists, Psychologists, Social Workers CPT HCPAC: reviews applications for new or revised CPT codes for non-physician specialties RUC HCPAC: reviews recommendations for the RVU for physician work and practice expense for non-physician specialties

Conversion Factor 2016 Conversion Factor = $ (as compared to $ from 2015) CF remains stable with annual payment increase of 0.5% thru 2019 Payment frozen from 2020 to 2025 After 2025 payment adjustments based on participation in alternative payment models and quality measures More on that in Part 2 Dee 11 cents difference Something major happened last April Method used to determine CF no longer is used.

Medicare Physician Fee Schedule (MPFS)
All references to MPFS include the 80% that Medicare pays and the 20% patient coinsurance Many private insurers and Medicaid programs model their own payments on Medicare’s MPFS ends up largely determining physician incomes…and ours too…all Medicare Providers MPFS appears in Final Rule usually around Nov 1 for following year other health care payers often use the AMA RVU scale and adjust the conversion factor up or down

2016 Medicare Physician Fee Schedule ASHA – Speech-Language Pathology
Dee Column 4 has instructions and links

Common (not all) SLP Evaluation CPT Codes
Evaluation of speech fluency Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria Evaluation of speech sound production with evaluation of language comprehension and expression Behavioral and qualitative analysis of voice and resonance Evaluation for prescription of speech-generating AAC device, face to face with patient, first hour Evaluation of oral and pharyngeal swallowing function Assessment of aphasia with interpretation and report, per hour Common but not all…92597 Voice prosthetic (TEP), MBS, FEES

Common (not all) SLP Treatment CPT Codes
Treatment of speech, language, voice, communication, and/or auditory processing disorder Group, 2 or more individuals Treatment of swallowing dysfunction and/or oral function for feeding Therapeutic services for use of speech-generating device, including programming and modification Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact by provider, each 15mins

MPFS Audiology Codes CODE 2015 Fee 2016 Fee $37.73 $ $32.34 $ N/A $ N/A $ $ $ $ $ $21.56 $ $33.42 $ – Fee-For-Service - $88.00 for CPT 92557

Common Audiology CPT Codes
92557 – Comprehensive audiometry, bilateral (air, bone, speech) Tympanometry 92568 – Acoustic reflexes 92369 – Acoustic reflex decay 92550 – Tympanometry and reflexes 92570 – Tympanometry reflexes, and reflex decay 92540 – Bundled vestibular (4 categories) Caloric vestibular test with recording, bilateral; bithermal (4) Caloric testing with recording, bilateral; monothermal (2) 92587 – OAE; limited 3-6 frequencies (interpretation and report) 92588 – OAE; Comprehensive min 12 frequencies (Interp and report) 92585 – Auditory evoked potentials; comprehensive

Rules and Tools for Coding Efficiency

Coding Clarifications – Edit Systems
National Correct Coding Initiative (CCI) – any Part B services not rendered in a hospital Outpatient Code Editor (OCE) – outpatient hospital services, very similar to CCI Automated edit systems used by CMS to control specific CPT code pairs that can be reported on the same day for the same patient CCI is updated quarterly and OCE follows one quarter later Since 2010, CCI applies to Medicaid per federal law Dee - For example – was an edit on and so that eval and tx could NOT be given to same pt on same day. ASHA got removal 2004 ASHA’s website has tables listing current CCI edits for speech-language pathology and swallowing procedures

Coding Clarification Modifiers SLPs need to know
-59 Distinct and Separate Procedural Service Only modifier used with NCCI edits For two procedures not ordinarily performed on same day by same practitioner, but which, under certain circumstances, may be appropriate to perform and therefore code on the same day (e.g., different site or organ system) CPT (MBS) & (Clinical Swallow Eval) CPT (Dysphagia tx) & (Cog tx) CPT (Group tx) & (Indiv tx) CPT (Aphasia assessment) & (Cognitive Performance testing) -52 Indicates Shortened Procedure Dee Modifiers are determined by CMS. You can not decide that I’m going to put -59 modifier on this procedure b/c I think it’s distinct ad separate. Modifiers provide information to CMS; For example: and 92520; (clinical eval of swallow) and (MBS)

ASHA CCI Edit Page for SLP Codes
Dee – example (FEES) can not be done on same day as (dx flexible endoscopic eval) Point out with or and can not be billed with 92523 SLP CCI Edits can be found at

Coding Clarification Modifiers Audiologists Need to Know
22 – Increased procedural services 26 – Professional component TC- Technical component 52 – Reduced services 53 – Discontinued procedure GA – Mandatory use of ABN GY – Statutorily excluded service Ex., Denial for secondary insurance

CCI Edits for Audiology Codes
69210 (cerumen management) cannot be billed on the same date of service with audiometric/vestibular tests If they are billed together, CMS will only pay for audiometric/vestibular! Can bill G0268 (Removal of impacted cerumen, one or both ears by physician on same date of service as audiologic function testing) for cerumen with 92557, for example

Medically Unlikely Edits (MUEs)
Subset of CCI edits also for Medicare Part B and Medicaid claims Specifies maximum number of times that a CPT code can be reported on same day for same patient Separate MUEs for office and hospital outpatient settings, but SLP MUEs are similar for both speech tx dysphagia tx clinical eval of swallowing standardized cognitive performance testing per hour aphasia assessment per hour For complete list of SLP-related MUEs, see:

Timed versus Untimed Procedure Codes Applies to Out-patient (Part B) Services
Most CPT codes reported by SLPs are NOT timed-codes Example: CPT (speech therapy) is NOT a timed-code, bill per visit, not unit of time Most SLP codes represent a typical visit length Determined by membership survey during the development of the code Most CPT codes are billed as ONE visit Note: some state Medicaid agencies allow timed billing and multiple units Note: Does not apply to Part A Prospective Payment Systems Dee – Let’s talk about how we can appropriately use codes, modifiers, and edits to receive equitable reimbursement! First – timed codes *In some cases & places, Medicaid allows for timed billing. The value of the service is based on our professional skill and not the number of minutes we spend. This is a huge advantage for us and PT and OT are currently redeveloping their CPT codes **92507 has 50 mins of intraservice time built into the value of the code- professional work and expertise

Timed Versus Untimed Codes Specific SLP Timed Procedures
92607: Evaluation for prescription of speech-generating device, first hour 92608: each additional 30 mins 92626: Evaluation of auditory rehabilitation status, first hour 92627: each additional 15 minutes 96105: Assessment of aphasia, per hour 96125: Standardized cognitive performance testing, per hour 97532: Development of cognitive skills, each 15 mins

Timed Versus Untimed SLP Codes Time Requirements
Time documented must correspond to number of units billed on the claim Time spent must exceed halfway point dictated by the code: 1-hour unit ≥ 31 minutes ½ hour unit ≥ 16 minutes 15-minute unit ≥ 8 minutes Subsequent timed-units may not be counted until the full value (first code) plus ½ of the value is exceeded (second code)

Timed Versus Untimed SLP Codes Time Requirements - Example
An aphasia assessment took 60 minutes with the patient and scoring, interpretation and documentation took an additional 45 minutes. CPT = 1 hour per each unit billed, max of 3 To bill a second unit of 96105, 91 minutes must be documented on evaluation and report; (first hour + ½ of second hour + 1 min) In this case, 105 minutes are documented. It is appropriate to bill 2 units of

Multiple Procedure Payment Reduction Policy (MPPR)
Applies to any and all therapy disciplines performed on the same day Does NOT include audiology at this time Therapy service or unit with highest practice expense (PE) value receives full reimbursement For additional services provided on same day, CMS reduces PE by 50% (but not professional work or malpractice expense components) Dee – Purpose – to cut down on duplication of practice expense (i.e., supplies, equipment, and indirect costs) Thank goodness we revalued our codes to include professional work and decrease practice expense! Still worried about 92506…if SLP eval and PT eval in same day, the PE in the second procedure may be cut by 50% Good thing, then, that the PE for went up so much. Maybe that will compensate a bit

Multiple Procedure Payment Reduction
Primarily affect professions that bill multiple procedures, or bill a timed procedure more than once per visit Ex: If and are provided on same day, payment of PE for would be reduced by 50% since PE is less for speech/lang tx than dysphagia tx MPPR is a per-day policy that applies across disciplines and settings If SLP and Physical Therapy both provide treatment to the same patient on the same day, the MPPR applies to all codes billed that day regardless of discipline Code with greatest PE gets full payment and others have PE reduced Dee- We have very low PE so SLP not hit quite as hard as PT and OT PE is higher and they bill multiple units of tx ; Remember this when you think about billing multiple units of versus 92507

SLP/PT Therapy Fee Cap Balanced Budget Act of 1997 Congress placed an annual cap on rehab services under Medicare; Began 1999 2016 combined PT and SLP cap = $1,960 per beneficiary per year; OT – individual cap $1,960 Two-tiered exceptions process Automatic exceptions Manual medical review exceptions Automatic exceptions - Use KX modifier, if applicable, for those who have exceeded the cap Therapy cap in effect until December 31, 2017 Discuss the 2-tiered exception process; CMS feels that beneficiaries who have potential for meaningful benefit from skilled care will not be denied KX soft limit – your documentation is critical to provide rationale and patient’s progress etc Repeal effort part of the Medicare Access and CHIP Reauthorization Act The therapy cap repeal effort failed by a vote of 58 to 42 (needed 60 votes to pass)

Resources for Medicare Fee Schedule, Edits, and Modifiers

SLP CodinG Scenarios Dee Let’s Practice Coding!

Case Scenario CPT Coding Question
The patient had a cerebral infarct and presents with aphasia and dysarthria. Which evaluation procedure code(s) is/are your best choices? CPT (speech sound production with receptive & expressive language) CPT (aphasia assessment per hour) and CPT (speech sound production) CPT and CPT 92522

Case Scenario CPT Coding Answer
Best choice of evaluations for CVA and dysarthria: Choice B CPT (speech sound production) and CPT (aphasia assessment per hour) Use -59 modifier on the second procedure

Case Scenario ICD-10 Coding Question
The patient had a cerebral infarct and presents with aphasia and dysarthria. Which diagnostic code (s) (ICD-10) is/are your best choice? I Aphasia following cerebral infarction I Dysarthria following cerebral infarction I69.32 Speech and language deficits following cerebral infarction R47.01 Aphasia R Dysarthria and anarthria

Case Scenario ICD-10 Coding Answer
Answer is : A I Aphasia following cerebral infarction I Dysarthria following cerebral infarction I69.32 is not the most specific code choice R47 codes have an “Excludes 1” excluding aphasia and dysarthria following cerebrovascular disease I69.

Ms. Jones has Parkinson’s disease and presents with impairments of expressive/receptive language, motor speech and voice. Which evaluation procedures are appropriate? A: CPT (speech sound production with expressive/receptive language) and CPT (behavioral and qualitative analysis of voice and resonance) B: CPT and CPT (speech sound production) C: CPT and CPT 92524

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

Case Scenario Billing Multiple Units Question
The evaluation for cognitive status using standardized measures took 50 mins with the patient. The interpretation and report writing took 30 mins and was documented in the medical record. How many units of CPT (1 hr/ea unit) may be billed for this evaluation? A: one unit B: two units

Case Scenario Billing Multiple Units Answer
The Answer is: A CPT is a timed code and may be billed in 1-hour units of time for a maximum of two units. In this case 80 mins are documented in the record. It is appropriate to bill only one unit of CPT To bill a second unit of 96125, 91 minutes (first hour + ½ of second hour + 1 min) must be documented for the evaluation, interpretation, and report.

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

Case Scenario ICD-10 Answer
The answer is… C….Maybe R48.8 Other symbolic dysfunctions F84.0 Autistic disorder Use symbolic dysfunction rather than F80.2 (Mixed receptive-expressive language disorder) since there is an underlying disorder contributing to the language problems. F80.2 is in the “developmental” section. Under question is the order of these two codes; that is, Primary versus Secondary ASHA seeking guidance on this issue

Case Scenario ICD10 Question
A 5-year old child was referred to SLP by pediatrician for evaluation of unintelligible speech. ICD-10 code from the physician was F Evaluation of speech sound production was completed and child’s articulation was within normal limits. What is the correct ICD-10 code for the evaluation? A: R Dysarthria B: O.0X0X Normal C: F Phonological disorder

Case Scenario ICD-10 Answer
The answer is C – Phonological Disorder There in NO CODE to indicate normal Explain results in the documentation

Case Scenario ICD Coding Question
The patient has been diagnosed with Alzheimer’s disease. SLP treatment focuses on improvement of communication. What ICD-10 codes do I use?

Case Scenario ICD Coding Answer
ICD-10 codes for cognitive-communication treatment for patients with Alzheimer’s disease: R48.8 Other symbolic dysfunctions G30.0 – G30.9 series for Alzheimer's disease (early onset, late onset, etc) G30 requires additional codes to identify dementia with or without behavioral disturbance (F02.8X series) There are levels of complexity of Alzheimer’s disease

Case Scenario – CCI Edits Question
SLP performs speech/language evaluation and treatment on the same date of service. What are the CPT codes to bill? A: None, cannot bill for both of these procedures on the same day B: CPT and 92507 C: Only CPT 92523 73 73

Case Scenario NCCI Edits Answer
The answer is: B CPT Code(s): and 92507 No modifier needed; no edit indicating an evaluation and treatment cannot be done on the same date Would need to have Plan of Care (POC) by next day if Medicare If private insurance, they might want to approve POC before authorizing treatment. In that case, do not schedule therapy on the same date Know your payers! 74

I am treating an 11-year old who has been diagnosed with ADHD and is struggling in the classroom because of poor attention and memory skills. I work directly on memory enhancing techniques (e.g., chunking) and compensatory strategies. Can I bill CPT (cognitive treatment per 15 mins)?

It seems that your treatment matches the procedure code description. It will depend on your payer: If CPT is not covered, then CPT (speech and language therapy) would be an appropriate choice You may NOT use both on the same date CPT is a timed 15-min procedure CPT is an untimed code Remember MPPR reduction on multiple billings

A 4-year old child was referred for a speech and language evaluation. I spent two hours on the first visit and completed the evaluation on the second visit. In addition, I spent one hour writing the report. May I code and bill CPT (Evaluation of speech-sound production with evaluation of language) for each visit?

No, remember that CPT is an untimed procedure code. You may only bill one time for the initial evaluation CPT Try to complete enough of the evaluation on the initial visit so that you may determine a plan of care You may complete additional assessment as needed on the second visit and bill as part of the treatment CPT

RESOURCES ASHA Reimbursement and Advocacy Modules for SLPs and Audiologists FREE! 9 modules, 10 to 20mins each Designed for graduate students but used by all In 2014, 4,000 hits per quarter AAA Resources: E-Audiology Coding and Reimbursement Series:

Audiology CodinG Scenarios
Paul Let’s Practice Coding!

Let’s Practice A patient presents with impacted cerumen and you want to remove it. It is within your state scope of practice to remove cerumen, but Medicare considers it a treatment code, and audiologists are credentialed to perform diagnostic services. Conundrum: The patient insists that secondary insurance will pay for the cerumen removal, but you know it is illegal to bill Medicare for a service that is not covered. What do you do? Ans: Bill Medicare using and affix the “GY” modifier. On line 19 of the CMS 1500 form add “need denial for secondary insurance”

Pondering the ABN Do you need to have the patient sign an ABN? ANS: Under Medicare, an audiologist is statutorily prohibited to bill Medicare for cerumen management, therefore, it is NOT necessary to have the patient sign the ABN. The patient, however, can be billed as an out-of-pocket expense and the Medicare Physician Fee Schedule does not apply.

Bundled Codes 92557, comprehensive audiometry threshold evaluation and speech recognition (92553, air and bone, and 92556, speech testing combined) is listed in the MPFS as $ If one was to bill both and individually, the Medicare payment doubles? Why not bill and instead of 92557? ANS: It is illegal to bill for the components of a bundled code if all components of the bundled code are being billed. The rationale is that the RVU is less for the bundled because redundant services occur with a bundled code

Free FACT: Medicare does not allow a Medicare patient to be billed more than a non-Medicare patient. Scenario: Your clinic is having a marketing campaign which invites Medicare beneficiaries to come in to your clinic and have a free hearing test – 92557 Question: Is this a good marketing strategy? ANS: Can no longer bill MC patients for this equivalent service (could do a screening) Medicare can’t be billed due to no physician referral and a lack of medical necessity

ICD-10 A patient presents with a left conductive hearing loss and a right sensorineural hearing loss, but there isn’t a code to represent this presentation. What do you do? ANS: Code A. H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side B. H90.42 SNHL, unilateral, left ear, with unrestricted hearing on the contralateral side Code both A and B H90.2 Conductive hearing loss, unspecified H90.5 Sensorineural hearing loss, unspecified Both D and E

Best Practices Your clinic believes that a patient should have an annual hearing test. As a courtesy to your patients, you send them a reminder. This is a good practice: If you have the patient obtain a physician referral before coming to your clinic For established patients because you already have a physician referral from the initial visit This would be considered soliciting a referral and is an illegal Medicare practice If you bill the patient, not Medicare ANS: C and D

CPT Modifiers A patient is scheduled for which is described as a binaural procedure. Your patient has a recent hearing test documenting normal hearing for the right ear, but a conductive loss in the left. You only perform a left ear test. How is this billed? Bill 92557 Bill with the 52 modifier Bill with the 53 modifier Bill and 92556 Either B or D ANS: B

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