Medicare Compliance, Coding and
Billing, and More:
What Every University Clinic Must Know
and Implement
Paul Pessis, AuD
Tim Nanof, MSW
Disclosures:
• Financial
• Tim Nanof is employed full time by ASHA.
• Paul Pessis is the owner/clinical audiologist of a private practice.
• Non-Financial
• Tim Nanof contributes to for-sale products developed by ASHA and is
the ex-officio of the health ASHA Care Economics Committee.
• Paul Pessis serves on the advisory boards of two hearing aid
companies.
Agenda:
•
•
•
•
•
•
•
•
•
•
•
Introductions, Disclosures and Resources
Coding
Changing Health Care Reimbursement Landscape
MACRA (MIPS & APMs)
Medicare “Things to Know”
Code Creation & Valuation Processes
The Business of Health Care
Coding Scenarios
Compliance Details & Discussion
Questions & Answers
Contact Information
American Academy Of Audiology
Advocacy Resources
• Key Staff Contacts:
• Kitty Werner, Vice President of Public Affairs: [email protected]
• Kate Thomas, Senior Director of Advocacy and Reimbursement:
[email protected]
• Adam Finkel, Associate Director of Government Relations:
[email protected]
• Commmittees
• Coding and Reimbursement Committee (CRC): E-mail questions to
[email protected]
• Practice Payment Advisory Council (PPAC)
• Government Relations Committee (GRC)
• Practice Compliance Committee (PCC)
• State Network Subcommittee (SNS)
ASHA Government Relations and
Public Policy: (GRPP)
• Federal Affairs Team: Ingrid Lusis [email protected]
• Neil Snyder, Sam Hewitt, Catherine Clarke, Erik Lazdins, PAC
Director (vacant)
• State Advocacy Team: Janet Deppe [email protected]
• Susan Adams, Cheris Frailey, Eileen Crowe
• Health Care Economics & Advocacy Team (HEAT):
•
•
•
•
•
•
Tim Nanof [email protected]
Janet McCarty: Private Health Plans [email protected]
Neela Swanson: Coding and AMA Liaison [email protected]
Laurie Alban Havens: Medicaid [email protected]
Daneen Grooms: Health Reform (ACA) [email protected]
Kate Ogden: Health Policy Associate- Telepractice, Medicare
Advantage [email protected]
• Sarah Warren: Medicare [email protected]
Coding
HIPAA Compliant Code Sets
• CPT – Procedural codes
• Owned by the AMA
• ICD-10 – Diagnosis codes (~155,000)
• First change in 30 years
• HCPCS – Primarily used to identify products
such as hearing aids
INTERNATIONAL CLASSIFICATION OF
DISEASE, 10TH REVISION, CLINICAL
MODIFICATION
7
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
Laterality and Placeholder
• Laterality:
• 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
New ICD-10 Options for 2017
• H90.A11 Conductive hearing loss, unilateral, right ear with restricted
hearing on the contralateral side
• H90.A12 Conductive hearing loss, unilateral, left ear with restricted
hearing on the contralateral side
• H90.A21 Sensorineural hearing loss, unilateral, right ear, with
restricted hearing on the contralateral side
• H90.A22 Sensorineural hearing loss, unilateral, left ear, with
restricted hearing on the contralateral side
• H90.A31 Mixed conductive and sensorineural hearing loss, unilateral,
right ear with restricted hearing on the contralateral side
• H90.A32 Mixed conductive and sensorineural hearing, unilateral, left
ear with restricted hearing on the contralateral side
• H93.A Pulsatile tinnitus
•
H93.A1 Pulsatile tinnitus, right ear
•
H93.A2 Pulsatile tinnitus, left ear
•
H93.A3 Pulsatile tinnitus, bilateral
•
H93.A9 Pulsatile tinnitus, unspecified ear
The “Key”
Be Specific…
• H91.21 Sudden idiopathic hearing loss, right ear
• H83.3X3 Noise effects on inner ear, bilateral
• H93.11 Tinnitus, right ear
• H93.231 Hyperacusis, right ear
• H83.02 Labyrinthitis, left ear
• H91.03 Ototoxic hearing loss, bilateral
• H93.243 TTS, bilateral
Third party payers want specificity which needs to
be supported with detailed chart documentation
Quiz
• What constitutes a proper diagnosis?
• Hint: three things
• History
• Symptoms
• Findings
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”
15
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
• F80.89 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
16
ICD Coding Principle
•ICD code (reason) and CPT code (procedure) should
correspond for encounter.
•SLP Example
•ICD R13.11 Dysphagia, oral phase
•CPT 92610 Clinical Swallow Evaluation
•Audiology Example
•ICD H90.11 Conductive hearing loss, unilateral, right ear, with
unrestricted hearing on the contralateral side
•CPT 92557 Comprehensive audiometry threshold
evaluation and speech recognition (92553
and 92556 combined)
17
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”
• I69.391 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
18
ICD Coding Principle – relatively 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.-)
19
ICD Coding Principle
relatively 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
20
ICD Coding Principle – relatively 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.-)
21
New SLP related ICD-10 Codes
• http://www.asha.org/Practice/reimbursement/coding/Newand-Revised-ICD-10-CM-Codes-for-SLP/
• Highlight:
New SLP related ICD-10-CM Code
Other Developmental Disorders of Speech and Language
F80.82 Social pragmatic communication disorder (Excludes1:
Asperger's syndrome [F84.5], autistic disorder [F84.0])
ASHA Note: The "Excludes1" note means that F80.82 may not be
reported in conjunction with F84.5 or F84.0.
Coding Clarification
Modifiers Clinicians 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
HCPCS – Level II
•
Used primarily to identify products, supplies, and
services not included in the CPT codes
•
Codes are alpha-numeric: They consist of a single
alphabetical letter followed by 4 numeric digits
•
Codes are maintained by the Health Insurance
Association of America, BC/BS, and CMS
HCPCS – Level II (cont’d)
• Examples include:
V5008 - Hearing Screening
V5014 – Repair/Modification of hearing aid
V5242 – Hearing Aid, analog, monaural, CIC
V5252 – Hearing Aid, programmable analog,
binaural, ITE
V5261 – Hearing Aid, digital, binaural, BTE
V5275 – Ear Impression, each
Hearing services are listed as V5000-V5999
American Academy of Audiology
Tools for ICD-10-CM
• www.audiology.org
• Go to PRACTICE MANAGEMENT
• Then select CODING
• On LEFT side of page, select ICD
1.
Editable superbill template for CPT, ICD-10, CPT Modifiers
2.
Comprehensive listing of audiology related ICD-10 codes with descriptor
Visit www.audiology.org, search key word “ICD-10” or
http://www.audiology.org/practice_management/coding/international-classificationdiseases-10th-edition
Comprehensive list of audiology codes:
http://www.audiology.org/sites/default/files/PracticeManagement/2016_2017_ICD1
0_ListofCodesPertinent2Audiologists.pdf
ASHA ICD-10 Resources
• ICD-10 Codes for Audiologists and Speech-Language
Pathologists
• http://www.asha.org/Practice/reimbursement/coding/ICD-10/
Frequently Asked Questions for Audiologist and SpeechLanguage Pathologists:
http://www.asha.org/Practice/reimbursement/coding/ICD-10CM-Coding-FAQs-for-Audiologists-and-SLPs/
Additional ASHA Resources:
•
•
•
•
•
•
•
Additional Resources
About ICD-10-CM for Audiology and Speech-Language Pathology
ICD-10 Preparation Checklist
The ASHA Leader: "Ready to Code and Bill ICD-10?"
The ASHA Leader: "Get Ready for ICD-10"
"ICD-10 Is Coming: Are You Ready?" (for sale, on-demand webinar)
"What are Your ICD-10 Coding and Billing Challenges?" (live web
chat replay)
• National Center for Health Statistics ICD-10 website
• Centers for Medicare and Medicaid Services ICD-10 website
• Coding and Billing for Audiology and Speech-Language Pathology
(for sale, book)
Links to ASHA Coding Resources
Audiology Superbill
• http://www.asha.org/uploadedFiles/Model-SuperbillAudiology.docx
• SLP Superbill
• http://www.asha.org/uploadedFiles/Model-Superbill-SLP.docx
• Correctly Connecting and Coding Diagnosis & Procedure Codes:
The balancing act between ICD-10 and CPT Codes…
• http://leader.pubs.asha.org/article.aspx?articleid=2595613
ASHA Superbills…
The Reimbursement Landscape is
Changing…
Pay-For-Performance
• A reimbursement model which compensates professionals for
reducing costs without compromising care
• What happened to FEE-FOR-SERVICE?
• A provider set his/her own fee schedule, insurance paid what
was “customary and usual” and the patient was billed for
what the insurance company didn’t pay
Disturbing Reality of
Medicare Reimbursement
CPT 92557 – Chicago Locality
• 1985 (fee-for-service)
$85.00
• 2009 MPFS
$49.47
• 2017 MPFS
$33.41
HMMMM
• Federal mandates are reinventing
reimbursement
• Affordable Care Act (ACA)
• Trump Care?? (AHCA?)
• Quality of care at reduced cost – what does
that really mean?
The Acronym Game
• ACA: Affordable Care Act
• ACO: Accountable Care Organization
• MACRA: Medicare Access and CHIP
Reauthorization Act of 2015
• MIPS: Merit-based Incentive Payment System
• MPFS: Medicare Physician Fee Structure
• PQRS: Physician Quality Reporting System
• QCDR: Qualified Clinical Data Registry
• RUC: Relative Value Scale Update Committee
Physician Quality
Reporting System: PQRS
• Recognized as the first Pay-For-Performance initiative
• Voluntary – participation avoids a penalty (once had an
incentive)
• Applies to Medicare Part B (outpatient services)
• Goal of PQRS:
• Improve the quality of patient care
• Facility compliance with PQRS is part of the Physician
Comparative Initiative
Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA)
• April 14, 2015, the Senate passed MACRA with a vote of 92-8
• Established a new payment structure for Medicare
• Merit-based Incentive Program (MIPS)
• Abolished the 21% annual threat of reduced payments
• Implemented a 0.5% increase for 2016-2019
• 2019 – 2025 rates will remain constant, but there will be a chance
to incur a bonus , or a penalty
• After 2025, rates will increase annually by 0.5%
• Established Alternate Payment Models (APMs) - multidisciplinary
approach to improving quality and cutting costs with
provider incentives
MIPS
• New payment mechanism that will provide annual
updates to providers effective 2019 (Based on data
collection from 2017)
• Replaces SGR with PERFORMANCE targets
• Performance based in 4 categories (100 points)
• Quality: Value-Based Modifier (30 points)
• Resource use: Value-Based Modifier (30 points)
• Clinical practice improvement activities (15 points)
• Advancing Care Information (25 points)
Clinical Improvement Category
• Data will be generated from beneficiaries
• Same-day appointments
• Care coordination (telehealth)
• Beneficiary engagement
• Patient safety
• Population management (monitoring population health)
• Participation in APMs
Eligibility for MIPS
• First two years, the following Part B providers are
eligible:
• Physicians, physician assistants, nurse practitioners, and
nurse anesthetists
• As of the third year, audiologists and SLPs are expected to
be included: 2019 reporting for 2021 payment adjustments
Alternate Payment
Models
APMs
• Details are not yet clear; Many different types are being devised
• ACOs, Bundled, Episodic, PCMH, etc…
• Team of providers – some may remain fee-for-service
• Degree of bonus is being speculated – to all?
• If a provider meets the APM, then don’t participate in MIPS
National Quality Strategy:
1.
2.
3.
4.
Patient safety – safe care without harm
Patient experience – engage patient and family
Care coordination – effective communication
Clinical care – effective prevention and treatment for
leading causes of mortality
5. Population/community health – community outreach to
promote better living
6. Efficiency – more affordable quality care and implementing
new health care delivery models
So, Where Are Audiologists/SLPs?
• Audiologists will not participate in the program until
at least 2019, effective 2021
• Leaves two years where audiologists will not have
required quality reporting of PQRS (2017-18)
• May have continuing education tied into MIPS, so may be
advisable to continue reporting
• Will audiologists be included in APMs?
• Ex. Vestibular
Some Facts/Impressions
•
Physicians are paid for an office visit, Evaluation and
Management Codes (E&M) to assess and
integrate a plan of action for the patient
•
•
Audiologists don’t, or do they???
MACRA appears to be physician centric
•
Kool-Aid?: Quality of care, but reduce cost
Medicare: Things to Know
Medicare: CMS
• Centers for Medicare and Medicaid Services (CMS)
• The national health insurance program for:
• People age 65 years or older
• Certain disabled individuals under age 65, including blind individuals
• Children/adults with End-Stage Renal Disease
Medicare
• The country is divided into 10 Regions
• Each Region is divided into localities
• Each Region is administered by a Regional
Medicare Carrier
• This Carrier is responsible for processing and
reviewing all MC claims
• Each Regional Carrier has the authority to
interpret Medicare law, so reimbursement
policies are not always consistent from
region to region
• Audiologists are credentialed as diagnostic providers
Medicare Part A:
Covered Services
• Hospitalization
• Nursing Care
• Home Health Care
• Hospice Care
Services performed IN a hospital setting for inpatients
Medicare Part A (cont’d)
• Note: Services performed on in-patients are
reimbursed under the DRG (Diagnosis Related
Group) system. Reimbursement goes to the
hospital
Outpatient University Clinic audiologists, for
example, will not be reimbursed for any inpatient
services
Medicare Part B:
Covered Services
• Home Health Care
• Clinical Laboratory Services
• Outpatient Hospital Services
• Ambulatory Surgical Services
Services performed in AN outpatient setting
National Provider Identifier (NPI)
• The standard unique health identifier for health care
providers
• 10-digit number that is permanently linked to the
provider (replaced the PIN/UPIN)
• Audiologists MUST use his/her own NPI when billing
Medicare
Medicare: Primary or Secondary?
• Medicare is Primary Unless:
• Pt. has automobile liability insurance/No-Fault
• Disability insurance is being invoked
• Employee Group Health Plan (EGHP) applies
• 65 Years of age or older, still employed
• Employer Supplemental Insurance
• Federal Black Lung Act
• Veterans Affairs
• Worker’s Compensation
Primary or Secondary?
Medicare is Secondary When:
1. Individual or spouse currently employed & covered
under EGHP
2. Company has 20 or more employees
3. Pt. is on MC disability & the company has 100 or
more employees
4. There is end-stage renal disease when an EGHP
applies
Maintain the “Status” Quo?
• Provider Status Options:
• Participating Provider (Par): Accept Assignment (AA)
• Medicare payment sent directly to the provider
• Non-Participating Provider (Non-Par):
• Medicare payment sent to the patient
• Limiting Charge under Non-Par
• Non-Par is 5% less than Par (AA)
• Limiting Charge is 10% more than Par (AA)
The AMA and Medicare Process
“Join” for the Creation of the
Medicare Physician Fee Schedule
RBRVS
• The Relative Value Unit (RVU)
• Cognitive Work
• Practice Expense
• Malpractice Expense
• Each component of the RVU is multiplied
by a geographic factor
Components of the RBRVS
Percent of Total Relative Value
Professional
Liability
Insurance, 4%
Practice
Expense, 44%
Physician
Work, 52%
CPT Editorial Panel
• 17 member panel responsible for maintaining, revising,
updating the CPT code set
• The panel consists of 17 members:
• 11 physicians who are nominated by the national specialty
societies and approved by the AMA Board of Trustees
• A physician each from Blue Cross and Blue Shield
• A Performance Measure representative appointed by the
AMA Board of Trustees
• American Hospital Association representative
• 2 members from the CPT HCPAC
Submitting a CPT Proposal
• Must give a complete description
• A clinical vignette describing the typical patient and the
work involved
• Diagnosis of patients for this procedure applies
• Support with peer-reviewed articles
• Evidence of FDA approval of drugs or devices used in the
procedure
• Support why existing codes are not adequate
• Can any existing codes be changed ?
Review Process
• AMA staff reviews the coding suggestion
• New requests are referred to the CPT Advisory
Committee
• If the committee agrees a new code is not needed, the
AMA staff does not proceed
• If a new code seems indicated, it is passed to the CPT
Editorial Panel
• The Editorial Panel either: adds a new code or revises
an existing, postpones or tables a code, or rejects it
completely
• There is an appeals process
Relative Value Scale Update Committee
RUC
• AMA created a panel of experts from
medical specialty societies to
• Develop relative values for new or revised
CPT codes
• There are 31 members with 21 members
appointed by the medical specialty
societies
• AMA Board of Trustees picks the AMA
Chair, as well as, the AMA
representative to the RUC
Giving A Code “Value”:
RUC Cycle
Required to survey at least 50 - 100 practicing providers
Recommendations presented to the RUC
RUC may modify or adopt before submitting to CMS
RUC recommendations submitted to CMS
CMS reviews recommendations with Carrier Medical Directors
Medicare Physician Fee Schedule (MPFS) published
RUC Cycle and Methodology
• RUC’s cycle for developing recommendations is
closely coordinated with both CPT’s
schedule for annual code revisions and
CMS’s schedule for annual updates in the
Medicare Payment Schedule
• CPT meets three times a year to consider coding
changes for the next year’s edition
• CMS publishes the annual update to the
Medicare RVUs in the Federal Register every
year
• These codes and relative values go into effect
annually on January 1
RUC Cycle
• Step 1: CPT’s new or revised codes are submitted to
the RUC staff
• Step 2: Members of the RUC Advisory Committee
review and indicate a societies’ level of interest on
developing a relative value recommendation
• Step 3: AMA staff distribute survey instruments for
the specialty societies to evaluate the work
involved in the new or revised code
RUC Cycle
• Step 4: The specialty RVS committees conduct the
surveys, review the results and prepare
their recommendations to the RUC
• Step 5: The specialty advisors present the
recommendations at the RUC meeting
• Step 6: The RUC may decide to adopt a specialty
society’s recommendation, refer it back to the
specialty society or modify it before submitting
it to CMS
• Step 7: The RUC’s recommendations are forwarded
to CMS in May of each year
Who Authorizes a Code and Proposes Value
for Allied Health?
• Health Care Professional Advisory Committee (HCPAC)
• CPT HCPAC: includes non-physician advisors who
develop and review CPT codes
CPT Codes are always reviewed by the CPT Editorial Panel
• RUC HCPAC: reviews recommendations for the RVU for
physician work and practice expense for non-physician
specialties
Only one professional organization can have a “seat” on
the HCPACs. AAA has representation for the CPT HCPAC
and AAA & ASHA share the RUC HCPAC seat
Health Care Professionals Advisory
Committee (HCPAC) Members
Audiologists
Chiropractors
Dieticians
Nurses
Occupational Therapists
Optometrists
Physical Therapists
Physician Assistants
Podiatrists
Psychologists
Social Workers
Speech Pathologists
RUC and RUC/HCPAC
• Proceedings are confidential
• Codes from all professions are examined in
great detail (5-year review)
• Supplies
• Complexity
• Budget neutral
• Values of codes fluctuate depending on what enters “the
mix”
• All codes will eventually be devalued
• The Medicare Trust Fund is running out of money
Survey Valuation Process
• Code is to be surveyed by those who personally
perform the procedure
• Compile the survey data
• 25th percentile
• Median
• For audiology, work with other organizations
who utilize that particular code
• ASHA
• AAO
• Neurology
• Consensus building, strategy
Components of a Survey:
“Breaking down” the Code
• Pre-service time
• Preparing the patient
• Intra-service time
• Procedure
• Report writing
• Post-service time
• Explanation
• “Clean up”
Did You Know…?
• The Medicare Physician Fee Schedule (MPFS) is used as
the “template” for reimbursement for managed care
third party payers
• Typically, contracts are negotiated at the MPFS rate for
a locality plus a percentage
•
For Medicare, audiologists are credentialed as
providers of diagnostic services
•
Do not have physician or limited licensed practitioner status
•
Thus, medical referral is mandatory
New for 2016 Was:
• Vestibular code 92543, each irrigation (binaural
bi-thermal stimulation 4 tests with recording)
eliminated and replaced with:
• 92537- Caloric vestibular test with recording,
bilateral; bithermal (ie, one warm and one cool
irrigation in each ear for a total of four
irrigations)
• 92538- Monothermal (ie, one irrigation in each ear
for a total of two irrigations)
There are no CPT changes for 2017!
CMS Rejected the RUC’s
Recommendation
• “The recommendations for these services overstate the work
involved in performing these procedures.”
• Survey data states otherwise
• Who are the CMS subject experts?
• Every code is supported by reference codes that are to
support the society recommendation
• CMS has to give reference codes to support their
recommendation
• They selected a code that hasn’t been surveyed for 12 years
and only had 16 respondents
Tail Wagging the Dog?
• So, should the professions of
Audiology and Speech/Language
propose new codes?
• If we don’t, patients will have more
out-of-pocket expense
• Is this a problem?
What Is Insurance?
• A contract between the PATIENT
and the INSURANCE COMPANY
Audiology is a Business!
Continually Reassess
Business Practices
• How is documentation?
• Does it support medical necessity for Medicare patients?
• What is your profit margin for cost of goods? Cost of
“doing” business?
• How often is a fee schedule revised?
• How often are reimbursement levels analyzed?
• What are the utilization numbers for a health plan?
• Do you verify benefits?
• What do you give away for “free”? Is there always an
invoice?
• Need to know Correct Coding Initiatives (CCI)
• Use CPT modifiers when appropriate
Illegal To Bill Medicare For:
• Anything not medically necessary
• What is medical necessity?
• Needed for the diagnosis, direct care and
treatment of the patient’s medical
condition
• Meets the standard of good health practice (for
defined diagnostic purpose: not annuals)
• Is not for the convenience of the patient or
health care practitioner
• It is illegal for an audiologist to bill “incident
to” (billing diagnostic services performed
with a physician’s NPI) or services of an
audiologist assistant billed “incident to” an
audiologist
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, MC 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
• http://www.audiology.org/practice_management/coding/nationalcorrect-coding-initiative-cci-edits-audiology-procedures
Business Mindset
• Simply, a business mindset must be established
• Develop and then follow the “why”
• We Listen, We Know, We Treat... We Care
• Put the right people on the bus?
• Audiologists – how many?
• Front office – how many?
• Assistants – how many?
• Billing and Collections : How many?
• Medicare Physician Fee Schedule (MPFS): an
annual exercise
• Email addresses and cell phone numbers?
Business Mindset (cont’d)
• Financial policy needs to be signed by every
patient and enforced
• The policy must show that the patient is ultimately
responsible for unpaid covered services
• Confirm appointments ?
• Charge for missed appointments?
• Collection policy strictly enforced?
• Charge interest for overdue accounts?
• Payment plans? Are they really the answer?
• Review the Explanation of Benefits (EOB)
EOB
The Hidden “Gem” of Information
• Who in the practice reviews them?
• Forensic (analytic) review allows for:
• Best coding outcomes
• Assessing if the procedure performed exceeds the cost of doing
business
• Assessing the profitability of contracts with hearing aid benefits
• Tracking to see if a given plan covers procedures within the
audiologist’s scope of practice
• Determining if the current charge is too low
EOB
• A formal statement by the third-party payer that lists basic
insurance information and delineates how
reimbursement is allocated
• Sent to the patient and to the provider
• Examining and scrutinizing each EOB must be standard
business policy for maximizing reimbursement
• Discounts taken by the insurance company should be
compared against negotiated contracts to verify the
accuracy of write-offs
Explanation of Benefits (EOB)
• “Life-line” for a facility – It lists:
• Date of service
• Services rendered
• Fees charged
• Fees allowed by the insurance company
• Provider discount
• Amount paid by the insurance company
• Amount applied to the deductible of if the deductible has
been met
• Reason for denial of a billed service
EOB Terminology
• Co-Insurance: Percentage of the allowed amount due
from the patient. This percentage is often
higher if the patient sees a provider who is out-of-
network
• Co-Pay: The amount the insurance company requires the
patient to pay in addition to the co-insurance. If a co-
pay applies, it can be collected BEFORE the
patient is seen
EOB Terminology (cont’d)
• Write-off: The difference between the billed
amount and the allowed amount. You can’t
balance bill the patient for this difference
• Withhold: An HMO term that refers to a managerial
fee. Subtracted from the allowed amount and
can’t be collected from the patient
• Noncovered Benefits: Specific services that are
nonreimbursable by the insurance company, but
are billable to the patient
EOB
Medicare Odds & Ends
• Medicare beneficiaries have a deductible
• Medicare beneficiaries pay a monthly insurance premium
that is based on income
• Part A (hospital) Part B (Outpatient such as a University
Clinic)
• Co-Insurance
• Medicare Pays 80%
• Secondary “addresses the outstanding 20%
• Medicare beneficiaries have Part D – for medication
coverage
Simply, it isn’t a FREE ride!
Bill For What Is Performed
If Not To Insurance, Then To the Patient
Evaluation and Management
Codes
So…
• Many patients initiate their hearing and balance care with the
audiologist. The expectation is that the audiologist is the
appropriate gatekeeper for these concerns
• Making the appropriate recommendations and/or referrals
are predicated on taking a thorough case history
and selecting the appropriate test battery.
Counseling is essential for maximizing patient care
• Although every CPT code compensates the professional
for being cognitive specific to that code, the
evaluation & management (E&M) options address
the compensation required for the “global”
management and evaluation of patient care
Scope of Practice
• Taking a thorough case history is core for the delivery of quality
care. Results of the history needs to be well documented
• SOAP findings
• Document everything you ask and/or see as you evaluate the patient.
This includes the patient’s social and recreational history, as well
• Remember, if it isn’t written, it didn’t happen
• It is exceedingly appropriate for the audiologist to be compensated
for “bringing together” the history, findings from the visit,
and then devising a plan for patient follow-up
• E&M is part of the audiologist’s scope of practice. If the
insurance carrier denies payment, bill the patient
SOAP:
Is Your Chart “Clean”?
• Subjective – Patient’s description of the problem
• Objective – Physical findings on exam
• Assessment – Evaluation/findings
• Plan – Recommendation(s)
Method for standardizing charting within a facility
SOAP the Following
A Medicare 66 year old male was referred by Dr. Jones, a local
internist, with the complaint of tinnitus and reduced hearing.
His ears had mild cerumen which was removed by the
audiologist prior to the hearing test. The tympanic membranes
were intact, but the left TM appeared retracted. The ear
canals were healthy. His hearing test revealed a bilateral mild
to moderate sloping sensorineural hearing loss.
Tympanograms were normal for the right ear and -300 daPa
for the left. Acoustic reflexes and reflex decay findings were
unremarkable. It was recommended that the patient pursue
binaural amplification once he secured medical clearance.
Review of systems:
18 Categories
• Ears
• Nose
• Mouth
• Throat
• Neck
• Eyes
• Heart
• Lungs
• Breasts
• Stomach
• Urinary
• OB/GYN
• Endocrine/
Hormones
• Muscles & Joints
• Skin
• Blood & Lymph
• Neurologic
• Psychiatric
Evaluation and Management (E/M)
Codes
• Treatment codes used to compensate the provider for
evaluating the patient, directing care, and reporting
recommendations
• Audiologists can’t bill Medicare for these services
(physician/treatment codes) but other third-party
payers may reimburse for these codes
It is recommended to check with your payer
• Based on level of complexity
E/M Codes (cont’d)
• New or Established Patient Codes:
• New: 99201-99205
• Established: 99211-99215
• New patients haven’t seen the provider (or
associate in the same office) within the
past 3 years
• Established patients have been seen within
the past 3 years
E/M Codes (cont’d)
• Level of service is based on 6 components:
• History
• Examination
• Medical decision making
• Counseling
• Nature of presenting problem
• Coordination of care
• First three are key components in selecting the level
of service; the last three are contributory
The Mindful Practitioner is…
• studying the EOBs and looking at reimbursement and best coding
practices
• billing for all services rendered
• assessing overhead versus profit and knowing the break-even
billing rate per staff member
• understanding that all staff plays a role in securing success
• preparing for the arrival of OTCs: not a threat but an opportunity
• ensuring that the patient journey is professional and distinctive
• aware that Telehealth is close; going to implement proper coding
• engaging most physician specialists (PA’s and NP’s) to become
valued partners in patient care
The Mindful Practitioner is…
• establishing standard of care for a diagnostic evaluation
• Does it meet medical necessity for Medicare patients?
• What if some tests don’t?
• aware of what an insurance plans pay for a given service
• aware of how many “lives” are in an insurance plan and the
terms of a hearing aid benefit when it applies
AUDIOLOGY CODING SCENARIOS
Applying the Rules and Adhering
to Best Coding Practices
Scenario
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:
1. 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 69210 and affix the “GY” modifier.
On line 19 of the CMS 1500 form add “need denial
for secondary insurance”
Pondering the ABN
For this patient, do you need to have the patient sign an ABN?
ANS: Under Medicare, an audiologist is statutorily prohibited from billing
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
http://www.audiology.org/practice_management/reimbursement/medicare/ab
n-quick-reference-guide ; Other Resources:
http://www.audiology.org/practice_management/reimbursement/medicare/he
lpful-references-and-resources-related-abn
Free Scenario
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:
1. Can no longer bill MC patients for this equivalent service
(could do a screening)
2. Medicare can’t be billed due to no physician referral and a
lack of medical necessity
Best Practices Scenario
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:
A) If you have the patient obtain a physician referral before coming to
your clinic
B) For established patients because you already have a physician
referral from the initial visit
C) This would be considered soliciting a referral and is an illegal
Medicare practice
D) If you bill the patient, not Medicare
ANS: C and D
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?
A. CPT 92523 (speech sound production with receptive &
expressive language)
B. CPT 96105 (aphasia assessment per hour) and CPT 92522
(speech sound production)
C. CPT 92523 and CPT 92522
106
Case Scenario
CPT Coding Answer
Best choice of evaluations for CVA and dysarthria:
Choice B
• CPT 92522 (speech sound production) and CPT
96105 (aphasia assessment per hour)
• Use -59 modifier on the second procedure
107
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?
A. I69.320 Aphasia following cerebral infarction
I69.322 Dysarthria following cerebral infarction
B. I69.32 Speech and language deficits following cerebral
infarction
C. R47.01 Aphasia
R47.1 Dysarthria and anarthria
108
Case Scenario
ICD-10 Coding Answer
• Answer is : A
• I69.320 Aphasia following cerebral
infarction
• I69.322 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.
109
Case Scenario
CPT Coding Question
• 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 92523 (speech sound production with
expressive/receptive language) and CPT 92524 (behavioral
and qualitative analysis of voice and resonance)
B: CPT 92523 and CPT 92522 (speech sound production)
C: CPT 92522 and CPT 92524
110
Case Scenario
CPT Coding Answer
• Answer is A
• CPT 92523 (speech sound production with
expressive/receptive language) and CPT 92524
(behavioral and qualitative analysis of voice and
resonance)
111
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 96125 (1 hr/ea unit) may be billed
for this evaluation?
A: one unit
B: two units
112
Case Scenario
Billing Multiple Units Answer
• The Answer is: A
• CPT 96125 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 96125.
• 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.
113
Case Scenario
ICD-10 Question
• A child with diagnosis of autism is referred for a speechlanguage 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)
114
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
115
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 F80.0. 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 47.1
Dysarthria
B: O.0X0X Normal
C: F80.0
Phonological disorder
116
Case Scenario
ICD-10 Answer
• The answer is C – Phonological
Disorder
• There is NO CODE to indicate normal
• Explain results in the documentation
117
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 92523 and 92507
C: Only CPT 92523
118
118
Case Scenario NCCI Edits
Answer
• The answer is: B
• CPT Code(s): 92523 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 and
certified within 30 days.
• If private insurance, they might want to approve POC before
authorizing treatment. In that case, do not schedule therapy on the
same date
119
119
• 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 97532 (cognitive treatment per 15 mins)?
120
Case Scenario CPT Coding
Question
• It seems that your treatment matches the procedure code
description.
• It will depend on your payer:
• If CPT 97532 is not covered, then CPT 92507 (speech
and language therapy) would be an appropriate choice
• You may NOT use both on the same date
• CPT 97532 is a timed 15-min procedure
• CPT 92507 is an untimed code
121
Case Scenario CPT Coding
Answer
University Clinic ( & Private Practice)
Enrollment & Compliance
•
•
•
•
•
•
Opt-out
Supervision Requirements for Students & CF’s
Claims Submission
Participating & Non-Participating Options
Establishing rates and sliding scales
Medically Necessity, Skilled Care and Covered Service
• Diagnostics, treatment, Maintenance Consideration
Medicare Compliance Decision Tree…
Do you treat adults
with a disability or
over 65 years old?
Do you work in a
facility(e.g. SNF)?
Do not need to
enroll in Medicare
Do you work in an
office or private
practice?
Do not need to
enroll in Medicare
Enroll and bill
Medicare
123
Audiologists Can’t Opt Out Of Medicare
• CMS requires that covered services must be
submitted for Medicare beneficiaries
(Mandatory Reporting Requirement)
• To bill Medicare, you must be enrolled in
Medicare
• Approximately 30 days to obtain provider status
Speech-Language Pathologists Cannot
‘Opt Out’ Either
When providing a covered, medically necessary service to
a Medicare beneficiary speech-language pathologists must
comply with Medicare rules and submit claims.
Opt Out Exception
• Does not apply to non-covered services
• Hearing aids and related testing
• No-physician referral
• No medical necessity
However, if a beneficiary believes that a service may
be covered, a formal Medicare determination must
be granted!!!!!!!!
Supervision Requirements
Check with your payer… Medicaid and private health Plan
requirements vary dramatically from State to State/Plan to Plan.
Medicare Standards
• Students
• Personal (100% Direct)
Personal vs Direct
• Part A vs Part B
• Clinical Fellows
• Provisional licensure
• Registration (AL, TN)
• No Licensure (MA, CT, NY, DC, HI, PA*)
Supervision Details Continued…
• All state, payer and professional practice guidelines for student
supervision must be followed.
• Students and unlicensed CFs are considered extensions, not
independent of, the professional provider
• Although SNF supervision rules for Part A services are less stringent
than Part B rules, responsibility of care remains 100% with
supervising provider
Medically Necessity
• NAIC Definition:
• Health care services or supplies needed to prevent, diagnose or
treat an illness, injury, disease or its symptoms and that meet
accepted standards of medicine.
• Medicare Definition:
• Health care services or supplies needed to diagnose or treat an
illness, injury, condition, disease, or its symptoms and that meet
accepted standards of medicine.
Skilled Care & Covered Services
• Criteria for Skilled Care
• Criteria for Covered Services
• Considerations for:
•
•
•
•
Diagnostics
Treatment
Maintenance (Jimmo Settlement)
Therapy Cap ($1980 for 2017 with exceptions…)
For ALL Medicare Settings
• Patient is under care of physician and requires skilled therapy
services, as demonstrated by physician’s order for service or
signature on the plan of care (POC)
• All covered Medicare services must be reasonable and
necessary and provided at a level of complexity that requires a
qualified professional for safe and effective care
• Medicare Benefit Policy Manual refers to Medicare Part B
outpatient services as the standards for documentation
• www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.p
df
131
Speech-Language Pathology
What is Unskilled Care?
• 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 the session
• Repetition of same activities as in previous sessions
without noting modifications or observations
• Activities without rationale or connection to the goals
132
Speech Language Pathology
What is Unskilled Care?
• Observing caregivers without providing education or
feedback and/or without modifying plan
• Recording observations of beneficiary without providing
any direct treatment strategies
• Service can be self-administered
• Service may be furnished safely and effectively by an
unskilled person without direct or general supervision
133
Speech Language Pathology
What is Unskilled Care?
• 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
• Ask yourself, “Can this be done by someone else?”
Medicare Benefit PolicySkilled Care
• The services shall be of such a level of complexity and
sophistication or the condition of the patient shall be
such that the services required can be safely and
effectively performed only by a therapist…
• The deciding factors are always whether the services are
considered reasonable, effective treatments for the
patient’s condition and require the skills of a therapist, or
whether they can be safely and effectively carried out by
nonskilled personnel.
Speech Language Pathology
What is SKILLED Care?
• Analyze medical/behavioral data and select appropriate
evaluation tools/protocols
• Design plan of care (POC)
• Develop and deliver treatment activities that follow a
hierarchy of complexity to achieve the target skills for a
functional goal
• Based on expert observation, modify activities during
treatment sessions to maintain patient motivation and
facilitate success.
• Conduct ongoing assessment of patient response
136
Speech Language Pathology
What is SKILLED Care?
• Determine appropriate time for discharge or termination
of SLP service
• Explain rationale and expected results
• Develop maintenance program to be carried out by
patient and caregiver
• Train patients/caregivers in use of compensatory skills
and strategies
• www.asha.org/Practice/reimbursement/medicare/Docum
entation-of-Skilled-Versus-Unskilled-Care-for-MedicareBeneficiaries
Skilled Care & Covered Services
Case Example:
•
•
•
•
•
•
•
Woman Age 73
Medicare Enrolled
Late Effect CVA Receiving TX 5-Years Post-Stroke
Medical Necessity Criteria?
Functional impairment?
Treatment Goals?
Skilled Care? (SLP Tx, LPAA)
What determines Medicare coverage criteria?
Claim Submission…
Medicare is an Entitlement program.
• Medicare claims must be submitted for Medicare beneficiaries
when providing Medicare covered services.
• Participating vs Non-participating
• Pros & Cons
Establishing Rates & Sliding Scales
• Medicare Rates MPFS
• November Annually
• Participating/Non-participating
• The “limiting Charge”
The limiting charge applies to non-participating providers in the
Medicare Part B program when they do not accept assignment. The
limiting charge is 115 percent of the physician fee schedule amount.
The beneficiary is not responsible for billed amounts in excess of the
limiting charge for a covered service. (115% of 95%...)
Free care or reduced cost sliding fee scales…
Key Principles: Uniform and Equal Application Across Payers.
Is There an Alternative to Enrolling In and
Billing Medicare?
YES!
• Do not schedule Medicare beneficiaries
• If a Medicare beneficiary approaches you for treatment and
you do not want to enroll in and bill Medicare for the services,
then you must refer the patient elsewhere.
• You are allowed to say no to Medicare beneficiaries.
• Example- pediatric practitioners…
• Even if a beneficiary is willing to pay you out of pocket, you
can only see him/her if you enroll in and bill Medicare
• Alternately, SLPs could provide services “incident to” a
physician under the regulatory requirements for such services.
AAA Recommended Links
Medicare Physician Fee Schedule (MPFS)
http://www.ama-assn.org/ama/pub/physicianresources/solutions-managing-your-practice/cosing-billinginsurance/medicare/the-resource-based-relative-valuescale/overview-of-rbrvs.page
Mandatory Reporting and Opting Out
https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.pdf (p.103)
Medicare Frequently Asked Questions
http://www.audiology.org/practice_management/reimburs
ement/medicare/medicare-frequently-asked-questions
AAA Recommended Links
CMS/MACRA: MIPS/APMs
https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/Value-BasedPrograms/MACRA-MIPS-and-APMs/MACRA-MIPS-andAPMs.html
and
http://www.audiology.org/practice_management/reimb
ursement/medicare/medicare-payment-reform-meritbased-incentive-payment
Thank you.
Contact Information:
• Paul Pessis: [email protected]
• [email protected]
• Tim Nanof: [email protected]
• [email protected]