Medicare and Reimbursement Guidance from our StAMP and STAR Representative
STATE ADVOCATES FOR MEDICARE POLICY (StAMP)
STATE ADVOCATES FOR REIMBURSEMENT (STARs)
I am addressing some frequently asked questions:
“For Part B settings, is it acceptable to bill an evaluation code like 92526, and on that same day/for that same session bill a treatment code like 92507?
From my perspective, the simplest answer is that we should develop a plan of care that meets the patient’s clinical needs. This is regardless of the duration of the services needed or the estimated cost of care. I suggest the following plan:
- Development of the plan of care to meet the medical necessity of the patient.
- Document the clinical rationale (it’s helpful to reference evidence based practice).
- Assure medical record entries give evidence to the appropriateness and timeliness of the services provided.
With or without a therapy cap, it is possible you could find yourself having to appeal for payment of the services. If the plan is patient-centered and the clinical rationale is sound, you will be doing all you can to assure the patient gets appropriate care.
The CPT Code 97532 for cognitive treatment code has been discontinued as of 12/31/2017. ASHA report that this code has been discontinued due to over use by occupational therapy.
The replacement CPT Code is 97127. This is an untimed code.
CMS (Center for Medicare and Medicaid Services) reported that Medicare will NOT cover the 97127 CPT Code.
Medicare will cover the following for cognitive treatment G0515. This CPT Code is a timed code reported in 15-minute units.
The confusion is which code private payers will reimburse. Both CPT Codes can be billed by any payer.
This will mean each company will need to be contacted to discover which code can be billed to determine your reimbursement; which creates confusion and extra work for you in your treatment and business.
Montana Medicaid covers the G0515 CPT Code rather than the 97127.
Stay tuned to the latest updates on the therapy cap. As of the time that I am writing this report, the therapy cap is in the 20th year. ASHA is addressing abolishing the cap on therapies. To date the ability to appeal for additional sessions is nixed; however, my ASHA resources expect this to be appealed allowing for appeals for additional treatment sessions.
Montana Medicaid will NOT cover the 97127 for cognitive treatment.
I reached out to clarify the cognitive coverage for Montana Medicaid. I was contacted by Rena Stayaert, Montana Medicaid Program Officer, School Based Services, Optometric therapies.
She reported that the code that will be reimbursed for cognitive treatment by Medicaid is G0515 and the charge will be reimbursed in 15-minute units with a maximum charge per day is 8 units for a two-hour session.
For clarification Rena can be contacted by the following:
No new issues.
StAMP and STARs both are influenced by the following:
Multiple Procedure Payment Reduction (MPPR)
MPPR is a per-day policy that applies across disciplines and across settings. For example, if an SLP and a physical therapist both provide treatment to the same patient on the same day, the MPPR applies to all codes billed that day, regardless of discipline. Under MPPR, full payment is made for the therapy service or unit with the highest practice expense value (MPFS reimbursement rates are based on professional work, practice expense, and malpractice components) and payment reductions will apply for any other therapy performed on the same day. For the additional procedures provided on the same day, the practice expense (i.e., support personnel time, supplies, equipment, and indirect costs) of each fee will be reduced by 50% (effective April 1, 2013) for Part B services in all settings. The professional work and malpractice expense components of the payment will not be affected. ASHA has developed three MPPR scenarios to illustrate how reductions are calculated.
MPPR primarily affects physical therapists and occupational therapists because they are professions that commonly bill multiple procedures or a timed procedure billed more than once per visit. Eight speech-language pathology procedures are designated as applicable to MPPR.
Speech-Language Pathology Codes Subject to MPPR
- 92507 – Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
- 92508 – Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, two or more individuals
- 92521 – Evaluation of speech fluency (eg, stuttering, cluttering)
- 92522 – Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)
- 92523 – Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)
- 92524 – Behavioral and qualitative analysis of voice and resonance
- 92526 – Treatment of swallowing dysfunction and/or oral function for feeding
- 92597 – Evaluation for used and/or fitting of voice prosthetic device to supplement oral speech
- 92607 – Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour
- 92609 – Therapeutic services for the use of speech-generating device, including programming and modification
- 96125 – Standardized cognitive performance testing (eg, Ross Information Processing Assessment) per hour of a qualified health care professional’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
Please contact me if you have any issues/challenges with coding, documentation and reimbursement.
StAMP March 2017 Report
StAMP/StARS: Carol Morse
Lisa Satterfield has moved on to be working in the field of Audiology rather than as Director of Health Care Regulatory Advocacy and the StAMP in ASHA. Our new person is Sarah Warren. I will introduce her by listing her accomplishments in ASHA. Sarah Warren, MA Director, Health Care Regulatory Advocacy,
- Joined ASHA March 14, 2016
- Has worked on regulatory and legislative issues for 10 years in the therapy/rehabilitation space including at the American Medical Rehabilitation Providers Association and American Physical Therapy Association.
- Focused on Medicare Part A and B issues including implementation of MACRA and the IMPACT Act, responding to proposed rules, monitoring MMR implementation, audits and appeals, and quality measurement development and reporting.
- Submitting a proposal for the Convention with Renee Kinder on the Medicare appeals process.
1. Manual Medicare Review Update February 09, 2016The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy cap exception process through December 31, 2017 and modified the requirement for manual medical review for services over the $3,700 therapy thresholds. MACRA eliminated the requirement for manual medical review of all claims exceeding the thresholds and instead allows a targeted review process. MACRA also prohibits the use of Recovery Auditors to conduct the reviews. CMS has tasked Strategic Health Solutions as the Supplemental Medical Review Contractor (SMRC) with performing this medical review on a post-payment basis. The SMRC will be selecting claims for review based on: Providers with a high percentage of patients receiving therapy beyond the threshold as compared to their peers during the first year of MACRA. Therapy provided in skilled nursing facilities (SNFs), therapists in private practice, and outpatient physical therapy or speech-language pathology providers (OPTs) or other rehabilitation providers. Of particular interest in this medical review process will be the evaluation of the number of units/hours of therapy provided in a day. For CY 2015, the limit on incurred expenses (therapy cap) is $1,940 for physical therapy (PT) and speech-language pathology services (SLP) combined and $1,940 for occupational therapy (OT) services.
2. ALJ Delay
The Office of Medicare Hearings and Appeals (OMHA) which manages the third level of the Medicare Appeals process, the Administrative Law Judges (ALJs), held an appellant forum on February 25, 2016.During the forum, Chief ALJ Nancy Griswold released the most recent numbers associated with thebacklog. In FY 2015 OMHA received over 240,000 requests for a hearing and each ALJ team is able toprocess approximately 1,200 appeals a year. The backlog is estimated to be approximately one millionrequests for hearings and providers can expect to wait at least two years to have a hearing.OMHA also announced the expansion of the Settlement Conference Facilitation (SCF) pilot to Part Aclaims. This process brings together the appellant (e.g. the provider) and CMS through a mediator toachieve a settlement on claims pending a hearing. The SCF was developed in 2014 and was limited toPart B claims until this year. In the two years SCF has been available only 2,000 Part B claims pending ahearing have been resolved. Full details on the SCF can be found on the OMHA website at http://www.hhs.gov/omha/OMHA%20Settlement%20Conference%20Facilitation/SCF%20Part%20A%2 0Docs/medicare_part_a_administrative_law_judge_appeals.html.
2. Recovery Audit Program Changes Effective January 1, 2016
In November 2015 CMS announced a series of changes to the Recovery Audit program, including revised Additional Documentation Request (ADR) limits. Many of these changes were effective January 1, 2016. A full list of these changes can be found on the CMS website at
Compliance-Programs/Recovery- Audit-Program/Downloads/Recovery- Audit-Program-Enhancements11-6- 15-Update- .pdf.
3. CGS CGS, a Medicare Administrative Contractor (MAC) recently issued guidance on their website implementing an erroneous interpretation of Medicare guidelines for the provision of services in a SNF.
I participated in a presentation to state presidents with 2 of my StAMP colleagues in February.
News from CGS
Skilled Nursing Facility: Documentation Required to Bill Speech Therapy Services — When billing for speech therapy in the Skilled Nursing Facility (SNF) setting, the patient’s medical record mustcontain documentation proving medical necessity for the service. Patients who have been transferred to a SNF from a covered hospital stay must be treated in the SNF for conditions that were treated or arose during their qualifying hospital stay. If there is no indication that the patient received speech therapy during their hospitalization, speech therapy should not be billed by the SNF. If however, the patient’s condition changes while they are in the SNF, and the need for speech therapy can be documented as medically necessary, then and only then should the SNF bill for speech therapy.
Reference: CMS Medicare Benefit Policy Manual (Pub. 100-02) chapter 8, sections 10 & 30.2.2.
September 2015 – StaMP
STATE ADVOCATES FOR MEDICARE POLICY
STATE ADVOCATES FOR REIMBURSEMENT
|Mentors: Carol Morse, Anne VerHoef, Joan Jaeger|
|North Dakota||No rep|
|Oregon||Kathryn de Domingo||Kathy@progrehab.com|
|South Dakota||Laura Barberaemail@example.com|
|Region||States||MAC||Current LCDs||Future LCD|
|E||California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands||Noridian Healthcare Solutions, LLC||No speech||No speechL34210|
|F||Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming||Noridian Healthcare Solutions, LLC||No speech||No speech|
|HH&H||Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Michigan, Minnesota, Nevada, New Jersey, New York, Northern Mariana Islands, Oregon, Puerto Rico, US Virgin Islands, Wisconsin and Washington||National Government Services, Inc.||L27404
|HH&H||Delaware, District of Columbia, Colorado, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia, and Wyoming||CGS Administrators, LLC||L31905||L34083|
|DME D||Alaska, Arizona, California, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming, American Samoa, Guam, Northern Mariana Islands||Noridian Healthcare Solutions, LLC||L11524||L33739|
I am planning training at the MSHA Fall meeting in October to expand on Medicare .
ICD-10 will start October 1. Changes are that all ICD-10 begin with a letter and are 4 and 5 digits. Treating ICD is NOT the first item listed. Instead the ICD diagnosis is the initial item listed. Right or left side needs to be documented in identifying the accurate ICD-10 code.
Please go to ASHA site and log on and click practice and reimbursement for further information in transfer of ICD-9 to ICD-10. The ASHA site is most helpful.
State Medicare Administrative Contractor Network
The State Medicare Administrative Contractor Network (SMAC) has changed its name to the State Advocates for Medicare Policy (StAMP). The new name more accurately reflects the mission of the Network: to influence local public policy decisions that affect Medicare coverage and reimbursement of speech-language pathology and audiology services. While much of the work is accomplished with the Medicare Administrative Contractors, the group also discusses issues related to audits, medical review, quality and outcomes, Medicare payment, and related legislation. Network members serve as conduits of information for their state associations and ASHA and receive vital information on Medicare policies and laws, participate in monthly ASHA teleconferences, and assist in making changes at the federal and regional level. Ensure your members are playing by the Medicare rules—put your StAMP on it!
–Rachel Stansberry, M.A. CCC-SLP
Medicare administrative Contractors (MACs) are recruiting for ICD-10 end-to-end users.
To volunteer as a testing submitter:
- Volunteer forms are available on your MAC website
- Completed volunteer forms are due April 17
- CMS will review applications and select the group of testing submitters
- By May 8, the MACs and CEDI will notify the volunteers selected to test and provide them with the information needed for the testing
If selected, testers must be able to:
- Submit future-dated claims
- Provide valid National Provider Identifiers (NPIs), Provider Transaction Access Numbers (PTANs), and beneficiary Health Insurance Claim Numbers (HICNs) that will be used for test claims. This information will be needed by your MAC by May 29 for set-up purposes; testers will be dropped if information is not provided by the deadline
Contact your MACs if you are interested – and feel free to share!
Lisa Satterfield, M.S., CCC/A
Director, Health Care Regulatory Advocacy
American Speech-Language-Hearing Association (ASHA)
2200 Research Blvd. #220
Rockville, MD 20850
Don’t forget to contact your representative for the speech-generating device legislation. All of the information is here:
Action Alert: Help Remove Mandatory Medicare Rental Requirements for Speech-Generating Devices
Representative Cathy McMorris Rodgers (R-WA-05) has introduced the Steve Gleason Act of 2015, H.R. 628. This legislation would allow Medicare beneficiaries to immediately purchase and transfer ownership of speech-generating devices (SGDs) to the patient, thereby removing them from the Medicare capped-rental requirement. In addition, access to eye-tracking devices is included. The Senate is expected to introduce companion legislation in the near future.
SGDs have been subject to additional requirements due to reinterpretation of the Social Security Act and the issuance of a coverage reminder that prohibited SGDs from having any non-speech capabilities (e.g., e-mail, internet, environmental control) or the ability to upgrade in the future at the patient’s own expense. In addition, Medicare contractors are routinely denying coverage for eye-gaze, a technology that is needed by patients with limited or absent mobility in the arms and hands. Contractors indicate the denials are due to the ability of the eye-tracking to be used for other purposes or plugged into devices that are not SGDs.
In 2013, the Centers for Medicare & Medicaid Services (CMS) reclassified several devices, including SGDs, indicating that previous interpretation of the Social Security Act was inaccurate. ASHA has been working with the Amyotrophic Lateral Sclerosis Association (ALS), the SGD manufactures, and other key stakeholders to reverse this decision.
In April 2014, CMS applied the capped-rental rule, requiring patients to rent SGDs over a 13-month period before owning the device. Capped-rental adversely affects patients in an extended hospital stay or in a skilled nursing facility because Medicare will not cover the rental fees while the patient is in the rental period. It also prohibits any ability to unlock the devices to include non-speech capabilities.
Due to pressure from ASHA, ALSA, the SGD manufactures, and members of ASHA, CMS is revising their definition of an SGD and requested comments in November. The CMS National Coverage Determination is anticipated to resolve the non-speech capabilities issue, and is expected in July. Capped-rental, however, is defined by CMS as a legislative issue. The proposed legislation, if passed, will require CMS to reclassify the SGDs.
- Medicare Rescinds Speech-Generating Device Policies (11/7/2014)
- Medicare Delays September 1 Speech-Generating Device Policies (8/28/2014)
For more information on SGD issues, please contact Lisa Satterfield, ASHA’s director of health care regulatory advocacy, at firstname.lastname@example.org, or Ingrida Lusis, ASHA’s director of federal and political advocacy, at email@example.com.
Also, check out the ASHA SMAC webpage! Please double check your email that is on that page – remember it is the email that members will use to contact. If you want it changed, email me! http://www.asha.org/Practice/reimbursement/medicare/SMAC/
A couple of announcement from CMS from Lisa Satterfield:
- The Centers for Medicare and Medicaid Services (CMS) has awarded the Region 5 Recovery Audit contract to Connolly, LLC. The purpose of this contract is to identify and correct improper payments made for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS), and Home Health and Hospice (RFQ-CMS-2014-Region 5) claims. The current Recovery Auditors (RAs) is on track to continue active auditing through Dec. 31, 2015 as the legal challenges to contracts in RAC regions 1, 2, and 4 continue.
- For pre-payment reviews from MACs and Zone
Program Integrity Contractors (ZPICs) Additional
Documentation Requests (ADRs), providers and suppliers have 45 days to respond. Failure to respond within 45 days of a prepayment review ADR will result in denial of the claim(s) related to the ADR. Medical manual reviews are post-payment and managed by the RAC auditors, so this does not affect MMR. However, the MACs can request pre-payment reviews essentially when they want.
- 2015 claims will be delayed while MACs upload new rates.
The therapy cap legislation expired 3/31/2015! New legislation is in place. Follow ASHA headlines. PLEASE read the headlines and respond immediately to your congress folks to support this legislative action. ASHA has put in many hours in Washington to support increasing therapy monies from $1940 to $3700 or no cap at all. Expect quality and outcome based reimbursement rather than fee for service.
Carol Morse, Chair
IRF Proposed Rules: Medicare’s proposed rules for Inpatient Rehab Facilities and Skilled Nursing Facilities has been published, and ASHA will be commenting.
United HealthCare – Medicare Advantage: Notification has gone out nationally that UHC-MA is requiring G-codes on the claims for PT, OT, and SLP services for evaluation only. It is unclear what the purpose of collected outcomes data on evaluation-only services is,
Value-Based payment: There is more discussion in the community regarding value-based payment. Physicians currently have a value-based modifier system that requires them to add quality codes (similar to PQRS) to their claim in order to avoid additional 5% decreases in payment. PT has been discussing value-based payment – or payment related to quality and outcomes – and are starting to develop a clinical data registry for outcomes a little like NOMS, but more specific to the PQRS rules at this time.
Speech Generating Devices: There is a real possibility that SGDs will be significantly limited or unavailable to Medicare patients due to a policy that requires the devices to only function as SGDs and have no computer, wireless, or Bluetooth technology. The devices have to be
approved in order to be rented for Medicare patients (also a new policy), and the approval process is underway now. Some devices have already applied and been denied. If the manufacturers are able to make the application deadline (which is this week, because there is a 90 day review process), their devices will be stripped down to meet requirements. Some are not issuing devices to Medicare beneficiaries at all. The eye-gaze is also under scrutiny and being denied if it is purchased for a device that is no longer approved, or being denied because it has the capability to plug into other devices. Lew Golinker is a lawyer and expert in this area, and a good referral for patients. Lisa is working with him, the ALS Association, the manufacturers, the SIG, and has had meetings with Jonathan Blum and other CMS staff, the DME MAC medical directors, the DME PDAC medical director, and senators to find a solution. Please contact Lisa Satterfield, ASHA if you have patients without the ability to communicate because of Medicare policies regarding SGDs. You may contact Lisa: firstname.lastname@example.org,