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.
STARs March Report
Code 97532 – Cognition
There has been a correct coding edit (CCI) which precludes speech language pathologists from billing 97532 and92507 on the same day. However, this was originally implemented for the Medicare program, and some this is not allowed.
Many states allow for the practice of billing 97532 and if not allowed, whether cognition is allowed but billed under 92507. WV, NC do allow for cognitive treatment, billed under 92507. Robin will follow up to see if thetaxonomy for the SLP allows billing of 97532.
Physician signature required for service
SLPs do not require a physician’s referral for evaluation and treatment, unless required by the payer. I have submitted my name as a potential panel member in a Medicaid panel training course during the 2016 ASHAConference in Pittsburgh. I would represent the state of Montana and report and answer questions about Medicaid in Montana. I will be attending AASHA Connect in Minneapolis in July. Feel free to contact me with questions or issues in Medicare or Medicaid.
STAR Update September 2015
STAR Committee Report for 9-9-2015 Board Meeting submitted by Carol Morse
ASHA Develops Advocacy Guide for Rehabilitation and Habilitation Coverage
ASHA is collaborating with ASHA-recognized state speech-language-hearing associations to advocate for consistent, fair, and comprehensive coverage of rehabilitative and habilitative services and devices in each state’s health insurance marketplace. ASHA has developed a comprehensive advocacy guide, Essential Coverage: Rehabilitative and Habilitative Services and Devices, to be used by state associations and interested members, which explains the integral role audiologists and speech-language pathologists have in providing services to clients who require rehabilitation and habilitation services.It also provides clinical examples for when audiology and speech-language pathology services are medically necessary under the rehabilitative and habilitative services and devices benefit category. State association leaders can now use the document to advocate for more robust and comprehensive coverage in their state for rehabilitative and habilitative services performed by audiologists and speech-language pathologists. ASHA’s initiative includes a step-by-step guide to help state associations and members get started and determine who are their state contacts. The guide also provides a few talking points that state advocates can use when speaking to stakeholders, such as state regulators, legislators, or health plan officials.
The Patient Protection and Affordable Care Act (ACA) of 2010 requires all non- grandfathered health insurance plans offered in the small group and individual markets, both inside and outside of the marketplace, to provide benefits in 10 essential health benefit (EHB) categories. Rehabilitative and habilitative services and devices is one of the EHB required categories. On Friday, August 28, 2015, HHS published the list of the 10 EHB base-benchmark plans for each state for the 2016 and 2017 plan years. ASHA will review the base-benchmark plans for each state and will submit comments by the September 30, 2015 deadline.
For more information, please contact Daneen Grooms, MHSA, ASHA’s director of health reform analysis and advocacy, at firstname.lastname@example.org or by phone 301-296-5651. You can also contact your ASHA state liaison.Montana does NOT have managed Medicare. We do have management for Durable Medical Equipment. Spectrum Medical is the management for Montana Medicare durable equipment. I did attend the Heath Care Business Institute in July in Phoenix and plan to attend the STARs and Stamp in Denver in November. I also plan to provide additional training on Medicaid during the MSHA meeting in October.
Star members have noted that there are issues around evaluation vs assessment (refer to this Leader article about evaluation/assessment http://leader.pubs.asha.org/article.aspx?articleid=1784990 . Star members also stated that some Medicaid providers are going for consultation to minimize billing opportunities for SLP reimbursement for services.
Music therapy issue has come up in Illinois. The Star is working with the executive board to address this as music therapists are seeking licensure and wanting to charge on the SLP codes for payment. The executive board has also been in touch with Janet Deppe, ASHA’s Director of State Advocacy who has provided information to the State.
Michigan Star reported that in terms of managed care, there have been some issues. In two large hospitals, there were denying procedures, for video fluoroscopy but they discovered it was the facility portion that was being denied and not the provider part. Ultimately, this would affect providers in looking at total reimbursement and they are following up on this.
Save the Date – The Health Care Business Institute will held in Phoenix this year and the date has been moved from April (as that’s when it has been held in the past) to July 10-12. The meeting will be held at the same time and at the same location as the Schools Conference, though this is not a joint meeting. Traditionally, we have held an in-person meeting of the STARs on the night before the official start of the meeting, but because of a gala opening event on the night of July 9, we’ll be meeting in the afternoon probably 1-5.
Manage Medicaid is here!!! Changes to be alert to include expected requirements to obtain prior authorization for a evaluation and then submitting the evaluation to request treatment sessions. Medicaid will allow a specified number of sessions and then to continue treatment, additional sessions will need to be requested. The managed Medicaid requires parental involvement in the home with clear documentation of the training and home activities with parents OR clear documentation of reasons that the family was unable to complete the home activities or payment may be denied!
Please comment on two issues. First, are you aware of disparity in reimbursement provided to other professionals who are providing the same procedure? Refer to the following statement from Sam Hewitt, ASHA’s director of Political and Grassroots Advocacy:
I know that facilities/settings do get paid differently, but I’m sure there are cases of insurance companies saying to an AUD in a similar setting as an ENT that they get paid less for the same procedure based on academic qualification alone. In a nutshell, HHS did an FAQ document that went well beyond what it should have when clarifying the non-discrimination language to the point where they added in their own language and changed what the legislation was intended to do completely. Any sliver of evidence/example we could get of either of these things happening would be good.
Second, have there been problems with co-pay for speech-language treatments vs. doctors’ visits? Please refer to a 2012 article shared by Diane Ross (NV) addressing the co-pay problems http://www.kaiserhealthnews.org/Stories/2012/April/23/patient-physical-therapy-payments.aspx
I attended the STARS meeting in Las Vegas. Topics discussed were as follows:
Medicaid Managed Care
New CPT Codes’
The Business of Healthcare
This is a third party utilization review organization that handles prior authorization for services provided. Kathy D (OR) shared that this is used for other therapy services as well, and noted that the Oregon APTA chapter has been in following up with Care Core. She noted that it was started because there had been high utilization of services in her state. She also noted that Care Core is used for anyone accessing rehab services through Blue Cross/Blue Shield. Kathy stated that if a provider wants to deliver more than six visits, there is an extensive prior authorization process that is needed. She commented that this often led to an extensive delay and/or interruption of services. To address the challenges with Care Core, Kathy initiated a survey, initially in the state of Oregon, but they then extended the survey to other states. Kathy shared the finding from the survey with the STAR community. They were soliciting information about many facets of service delivery, including prior authorization.
Teresa (OK) noted that this prior auth process is used in the schools, often significantly delaying the amount of time until a child can be seen for treatment. Teresa noted that
because of significant problems with the process, the state has delayed implementation of the prior auth process until January 2015, and commented that this is for all OT/PT as well as SLP services. Teresa also commented that there had been some abuse of the system (notably limited to one specific group of providers) and as a result physician referral will be required as part of the implementation of this new procedure. Shannon reported on information that she provided to the state of Texas so that this could be addressed in her state, as they are also trying to eliminate/decrease fraudulent activity. STARs in other states also reported dealing with prior auth challenges. One area noted was difficulty in getting parental permission to e.g. where the kids are in a shelter and there may not be a parent to authorize this). Shannon did note that parent permission/parent involvement is needed. In South Carolina, Andy reported prior auth problems in her state, with specific problems with Molina(another utilization review organization), as they are looking for specific diagnoses to qualify for authorization, and as a result, are now denying many services. One of the things they’re looking for is standard scores and also, they are kicking out anything to do with sensory integration. Other states have had problems for treating children with developmental delay. Carol Morse reported that in Montana, for premies, OTs have been successful in getting authorization when problems are addressing taste/texture/food tolerance and Helen/Terri noted this for OTs in Tennessee as well. Shannon reported that in Texas, OTs have not been able to provide feeding treatment which goes against what most other states are allowing. Carol also recommended that when obtaining or attempting to obtain prior auth, that when prioritizing by medical need, e.g. for swallowing, that may be a life threatening situation, authorization would be easier to obtain.
New CPT Codes
Shelly (LA) discussed the challenge of using new codes, as their practice used to do a comprehensive evaluation and are now adjusting to the selection of only those modalities that are being assessed. Specific problem with the use of the -52 modifier if language (only) is being assessed. The group discussed the fact that articulation is often assessed (if not formally) and the clinical decision is made that articulation is not an issue, but the SLP has still addressed articulation to make that determination.
Andrea (SC) noted that the state is still slow to implement the new codes. As an example, she noted that it was believed (by payers) that only SLPs in hospitals provided swallowing evaluations and/or treatment. The state is slowly making changes
The group then discussed the use of codes and the special challenges of identifying medical model/educational model for the needed services. Shellie B (CA) who comes from an educational background stated that they the SLP has to do the assessment based on who is the payer and clinicians need to be aware of this distinction.
The Business of Healthcare
The coding discussion then led to a further discussion about preparation of students in terms of coding, knowledge of the use of codes and of course the need for preparation in how to document. This included a discussion about University level and where/how to contact to them in terms of the preparation of students – is there a role for the STARs in this? There was discussion about universities needing to provide more information about the business of healthcare. Laurie mentioned the (SERCU) modules developed
specifically for students at the University level that are available to everyone and that the modules included basic coding information as well as advocacy.
Carol (MT) emphasized the use of the concept of safety in defending the necessity of services, e.g. a client with a lack of language skills is at a higher risk for bullying.
The group also discussed the unique challenges for contractors providing services in the public schools and Terri/Helen discussed the situation in Tennessee about contracting with schools re: Medicaid/payment. They noted that Tennessee is contracting therapists going into the schools and the SLPs are required to pay a professional privilege tax that’s in addition to the licensure (22 professions were chosen) fee. There are some exclusive contacts with the schools from other therapy providers.
Medicaid Managed Care
Louisiana – for all populations except, early intervention
Texas – moving to Medicaid managed care
Oregon- moving to coordinated care organization, by regions. They are paying based on outcomes
Carol provided information about telepractice as this is a major issue in Montana. She discussed the fact that the states of Montana along with Wyoming and North Dakota are looking at this for practices in all three states. She noted that caseloads have tripled given the conditions treated, e.g. oral cancer. She noted that QA is not well defined. This will be legal as of 1/1/15. Other states are addressing this, including CA, OK, AK and TN. It was noted that Todd Houston has been a good resource on telepractice.