To receive reimbursement from Medicare and Medicaid, private practitioners must use the CMS-1500 claim form (dated 8/05) required by the Centers for Medicare and Medicaid Services (CMS). Many private health plans also use that claim form. Speech-language pathologists who choose to enroll as Medicare providers should be familiar with the requirements of this form (with a few exceptions, the information in this article also applies to non-Medicare payers).
Additional information addressing each entry on the form is available on the CMS Web site [PDF] (Chapter 26, "Completing and Processing Form CMS-1500 Data Set," of the Medicare Claims Processing Manual). ASHA members may also direct questions to email@example.com or their Medicare Administrative Contractor (MAC) or carrier. SLPs contracted as providers with a local Medicare Advantage Plan should direct questions to the managed care company.
View a sample of the form on the CMS Web site [PDF].
Q: Are there circumstances under which electronic submission of CMS-1500—rather than hard copy—is required?
If your practice has more than 10 full-time-equivalent employees you must file Medicare claims electronically. Electronic billing is permissible for all claims, however, and will speed the payment process; you can download free CMS software for electronic billing.
You may want to research proprietary billing services that will help submit claims, computerize your clinical documentation, and manage accounts receivable. ASHA has compiled a list, available upon request from firstname.lastname@example.org, of billing services and software that offer alternatives to manual billing and documentation (the list does not constitute endorsement of any company's services).
Q: Private-practice billing under Medicare for SLPs is effective July 1, 2009. May I submit claims for services provided immediately after that date?
* If you have submitted your enrollment application, but have not received acknowledgment of your enrollment in Medicare by July 1, you may still render services beginning July 1. Once you have been informed of your acceptance into the Medicare program, you may then retroactively bill Medicare for services provided on or after July 1. However, if your enrollment application is submitted after July 1, you may only retroactively bill Medicare for the services provided starting from the date you submitted your application.
Q: Diagnosis codes are an important element of the claim form. Where on the form do I list the codes? Is there a limit to the number of diagnoses listed?
There are spaces for up to four diagnoses:
The first diagnosis is entered in space 21.1. Official guidelines of the International Classification of Diseases, Ninth Edition (ICD-9), states that outpatient speech-language pathology services (including dysphagia) should be the "first-listed diagnosis" of V57.3, "Speech therapy." (There is a federal communication glitch: Some Medicare payers do not accept this code.)
The next code listed (space 21.2) should be the disorder or condition chiefly responsible for the outpatient services provided, such as late effects of cerebrovascular disease, speech and language deficits, aphasia (438.11).
Space 21.3 could contain any other disorder you are treating, if applicable.
The final codes would be secondary diagnoses, usually identified and assigned by a physician, that are causes of the disorder(s) you are treating (e.g., traumatic brain injury). You may also include physician-assigned conditions that exacerbate the speech-language problem if code slots remain.
Q: Are there restrictions on what primary or secondary diagnoses are allowed?
Most regional MACs have issued distinct Local Coverage Determinations (LCDs) for speech-language and dysphagia services that list ICD-9 codes that are covered. Some lists are all-inclusive; others may allow the SLP to include an unlisted code and document reasons for its use.
Q: Where do I insert CPT codes and under what circumstances may I bill for more than one CPT procedure on the same day?
Current Procedural Terminology (CPT, ©American Medical Association) is a description of the type of service provided on a specific day. The code is inserted in the first block at space 24.D. Each row represents a separate CPT code. Diagnosis #1, 2, 3 or 4 (the diagnosis most closely associated with the CPT procedure provided) is inserted in space 24.E. Dysphagia treatment codes and SLP treatment codes can always be billed on the same day as long as separate plans of care have been documented.
The ASHA Web site contains a Medicare list of Correct Coding Initiative (CCI) edits, which lists code pairs that (1) cannot be billed on the same day or (2) can be billed together if a specified modifier (59) is inserted in space 24.D. Go to ASHA's reimbursement Web pages for a full description of the CCI edit system.
Most SLP procedure codes are untimed and would therefore be billed as one unit per day. However, a single timed code (i.e., the official code descriptor is a timed unit such as 15 minutes or 30 minutes) can be billed multiple times on the same day. If the total service time for a 15-minute code is more than 7 minutes, you would bill for one unit; if total service time is more than 22 minutes, you could bill for two units (i.e., the duration of the last unit of evaluation or treatment must be more than 50% of the unit length). The number of units billed for the specific CPT code is inserted in space 24.G.
Q: Are there other CPT modifiers I should know about besides the "59" mentioned above?
Several years ago, Medicare began requiring all outpatient speech and language services to carry the "GN" modifier to help identify patients who have reached the annual expenditure limit (therapy cap) for speech-language and physical therapy services. There are also "22" and "52" modifiers, which denote unusually long/complex procedures (22) or procedures that take less than the typical amount of time (52). Some MACs pay an additional amount for procedures with the "22" modifier, which should be applied only to extreme cases.
Q: Is there a Medicare provider number in addition to my National Provider Identifier (NPI) number that is entered on the 1500 form?
Your individual NPI number (and group number, if applicable) is the means by which the MAC identifies you and your group practice. There is no separate Medicare provider number. The practitioner's NPI number is inserted in space 24.I. The same number also goes in space 33.a., "Billing Provider Information," unless a group practice is the billing entity.
Q: Space 28 says "Total Charge." How do I determine that?
Do not enter a charge here unless you are a designated provider for a local Medicare Advantage Plan, in which case you would enter the copay. All fees paid by Medicare are based on the CPT code and are determined by the Medicare Physician Fee Schedule. A copayment of 20% of the fee schedule amount must always be collected from the patient.
Q: Are there entries that are not relevant to Medicare and need not be completed?
Yes, some spaces are not relevant to Medicare. You can ignore spaces 11.d, 15, 22, 24.C, and 30 for Medicare billing.