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.