Q: Can audiologists or speech-language pathologists use the Evaluation/Management (E/M) codes found in the CPT* (Current Procedural Terminology) manual to describe and bill for their services?
Possibly—and you have to read carefully the American Medical Association's CPT Code Book because the E/M codes refer to physician services. Conversely, the introduction of the code book states, "Any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified health care professional." You can check to see if these codes are in any of your managed care contracts. We have heard from some audiologists and speech-language pathologists who report a limited number of the E/M codes to describe their services. Please note that some payers, such as Medicare, specifically do not allow non-physician providers to use the E/M series.
E/M codes are divided into broad categories such as office visits, hospital visits, consultations, home services, and case management services. Subcategories include "new" versus "established" patients, which are further classified into levels of E/M services; these levels capture skill, effort, time, and responsibility, using designations such as "expanded," "detailed," and "comprehensive" that require varying levels of medical decision-making (low, moderate, or high complexity). Thus, a new patient seen for an office visit with a presenting problem of low-to-moderate severity, in which the physician spends typically 20 minutes of face-to-face time with the patient, is coded under 99202. A new patient seen for a "comprehensive" visit of 45 minutes with presenting problems of moderate-to-high severity would be captured under 99204.
ASHA members who want to report a limited number of E/M codes to describe their services may be able to do so with managed care organizations (MCO), but the clinician must first obtain written acceptance from each MCO to use those codes. Also, the clinician and MCO must understand if and/or how the E/M codes will be billed in combination with other codes, such as 92506 (speech-language evaluation) or 92557 (comprehensive audiometry threshold evaluation).
A specific exception to the general physician-only use of E/M codes is a recently added E/M code series that describes medical team conferences (99366–99368) that capture both direct and non-direct patient care and specifically name "participation by non-physician qualified health care professionals." Interestingly, Medicare does not cover these team conference codes because the Centers for Medicare and Medicaid Services believe that the services are captured in standard E/M codes. Nevertheless, you should consider using this code because private payers may cover it.
Q: Are any clinicians successfully reporting services using E/M codes?
Yes, because it is important to report all services rendered. Clinicians are careful to communicate with the MCOs and check to see if the E/M codes can be used. I talked with an independent private-practice SLP who reviewed all potential codes that described the speech-language evaluation and treatment services she provides. She developed a set of code pairings that describe her services and, based on her claims-filing experience, are allowed by private health plans. She reports both E/M codes and codes from the 92000 series, such as 92507 (speech-language treatment). Standard reporting practices in her office include billing 92506 (speech-language evaluation) with 99202 (office visit for a new patient involving history-taking, examination, and medical decision-making of low-to-moderate severity and lasting 20 minutes).
For subsequent treatment visits, she combines 92507 and 99211 (office visit for an established patient in which the presenting problem is minimal and the visit is five minutes in length). The SLP notes that 99211 is documented as time spent discussing progress made during the session and reviewing activities outside of the treatment session that reinforce treatment goals.
I also had the chance to communicate with an audiologist who reports E/M codes in his practice. He stresses that ASHA members should make every effort to contact MCOs regarding policies on use of E/M codes, but he also notes that it is often "impossible" to obtain such information or have health plans respond. This audiologist believes clinicians can make a case for reporting the E/M codes, and that it is critical, regardless of the codes you bill, to make sure there is documentation in your report or chart notes detailing activities conducted.
His practice includes speech-language pathology services; he reports that for speech-language evaluations, 92506 is used with either 99203 (office visit of moderate severity lasting 30 minutes) or 99243 (office consultation of moderate severity lasting 40 minutes). For most audiological evaluations, he uses 99202, in addition to the audiologic procedures performed, such as 92557 (comprehensive audiological evaluation).
So, can SLPs and audiologists use E/M codes in addition to codes from the 92000 series to describe the services they provide for billing purposes? Instructions for use of CPT codes are presented clearly in the introduction of the CPT codebook, which directs practitioners to "select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided." The CPT codebook also says that "other additional procedures performed or pertinent special services are also listed."
Two clinicians have reported E/M codes successfully, but with caveats (e.g., written agreement from the MCO). MCOs may reimburse you, but it is prudent to get a written agreement with the plan allowing use of these codes. Be sure documentation supports all activities and procedures performed.
* CPT© 2007 American Medical Association. All rights reserved.