September 23, 2008 Bottom Line

Bottom Line: Billing and Coding Medicare Services

As of July 1, 2009, speech-language pathologists may begin direct billing of Medicare as private practitioners. The Medicare claims information outlined below is also useful in billing other third-party payers, such as state Medicaid programs, because they adopt many of the Medicare coding rules.

Q: What claim form is used by most private practitioners and group practices—physicians, dentists, social workers, physical therapists, and others?

The CMS-1500 Claim Form was developed by the Centers for Medicare and Medicaid Services (CMS) in collaboration with the American Medical Association and the private health insurance industry. Managed care organizations sometimes designate alternative billing forms.

The CMS-1500 is greatly dependent on accurate coding of services rendered. In addition to patient identification information, the most important information entered on the CMS-1500 are primary and secondary diagnoses (ICD-9-CM codes) and the Current Procedural Terminology® (CPT) codes for procedures rendered on specific dates. Medicare instructions for each numbered block on the claim form are available on the CMS Web site [PDF].

Q: How is payment determined?

A Medicare payment amount is associated with each CPT code entered on the claim form. The amount includes a 20% copayment by the patient. The list of codes and associated payment amounts are available on the ASHA Web site. Payments associated with private health plans are usually higher than Medicare rates.

It is anticipated that SLPs with a small number of Medicare patients will not be required to submit claims electronically. ASHA is researching the alternatives available for bill submission before the July 2009 implementation.

Q : How do I indicate procedures and services on the form?

The five-digit CPT codes are used to report all procedures and services. The official descriptor for each code specifies timed or untimed status. If no time is designated in the descriptor, the code represents a single session regardless of duration. Certain two-digit modifiers can be used to denote unusually short or long procedures. These modifiers are discussed on the ASHA Web site.

Full descriptors and special rules dictated by Medicare for speech-language pathology services are included in a table on the ASHA Web site.

Q: How do I report diagnoses and disorders?

All diagnoses are indicated by an ICD-9-CM (International Classification of Diseases, 9th revision, Clinical Modification) code. These codes have three digits followed by a decimal point and up to two additional digits. All five numerals should be used if the descriptor for the five-digit code accurately describes the disorder.

A "primary diagnosis" is the disorder being treated (i.e., the disorder for which a bill is submitted). Local Medicare policies may specify diagnoses allowed as secondary (i.e., disorders that are a cause of the condition being treated). For example, a polyp of the larynx (478.4, must be assigned by a physician) is a cause or secondary diagnosis for "other voice disorder" (784.49).

ASHA has prepared a list of ICD-9-CM codes that are primary and secondary to hearing, speech, language, voice, and swallowing disorders.

Note that ICD-9-CM "V-codes" are used to record a condition influencing health status or broad types of procedural, administrative, or screening encounters. V-codes are often not accepted for billing purposes by third-party payers.

CMS recently announced that the ICD-10 will replace the ICD-9, effective Oct. 1, 2011 (see story, p. 3). The ICD-10 will contain almost 10 times the number of code sets as the ICD-9. The ASHA ICD-9 link identified above will include information related to the development of new regulations.

Q: What codes are used to report supplies, equipment, and devices provided to patients?

The HCPCS (Healthcare Common Procedures Coding System) includes alphanumeric codes for these items and for a limited number of procedures not otherwise contained in the CPT system. HCPCS is administered by CMS in cooperation with other third-party payers.

CMS identifies HCPCS Level I as the CPT coding system; HCPCS Level II is usually referred to as HCPCS codes.

SLPs will usually not bill directly for supplies or devices. The cost of supplies is generally included in the payment for a speech-language or swallowing treatment session. Devices such as speech-generating devices are usually billed to Medicare by certified suppliers (durable medical equipment suppliers) who must adhere to comprehensive standards.

Q: How can I determine if two specific procedures can be billed on the same day?

CMS uses an automated edit system, the National Correct Coding Initiative (NCCI) Edits, to control specific code pairs that can be reported on the same day. NCCI—or more commonly, CCI—identifies "mutually exclusive" code pairings, codes considered to be components of more comprehensive services, or codes otherwise inappropriate to be delivered to the same patient on the same day.

An example of a "mutually exclusive" code pairing is 92607 (speech-generating device [SGD] evaluation) and 92597 (voice prosthetic evaluation). An example in the comprehensive/component list is 92506 (SLP evaluation) and 92607 (SGD evaluation). Certain code edits can be bypassed by attaching a "–59" modifier, which indicates that the two procedures are distinct and allows both to be billed. The distinct nature must be supported by your documentation in the medical record.

Relevant CCI edits are available on the ASHA Web site.

For further information, contact

Mark Kander, director of health care regulatory analysis, can be reached at

cite as: Kander, M. (2008, September 23). Bottom Line: Billing and Coding Medicare Services. The ASHA Leader.


Advertise With UsAdvertisement