Speech-language pathologists who treat Medicare Part B beneficiaries, heads up: beginning Jan. 1, you must begin reporting patient outcomes on claim forms. This change is the most significant of the SLP-related provisions in the 2013 Medicare Physician Fee Schedule, which also contains regulations related to reimbursement, reporting requirements, procedure codes, and other Medicare provider issues.
Here's what you need to know starting Jan. 1.
SLPs who provide services to Medicare Part B fee-for-service patients in all settings must report on patient progress and outcomes using G-codes on claim forms. This new requirement is part of efforts by the Centers for Medicare and Medicaid Services (CMS) to collect data that may be used to create a new Medicare reimbursement system for therapy services. CMS will reject claims that do not include the required information.
To comply with the new rules, SLPs must report on seven functional communication measures or one generic measure. The measures, adopted from ASHA's National Outcomes Measurement System (NOMS), are each described as a G-code, with a seven-point severity modifier system that corresponds to the NOMS functional communication measures (see "Success in Medicare Rules: ASHA Advocacy at Work").
In essence, SLPs must report one functional communication measure for every Medicare Part B beneficiary at admission, discharge, and every 10th treatment day. The codes must be documented in the medical record. Although the rule mandates reporting to start Jan. 1, the first six months of 2013 will be considered a transition period. Beginning July 1, claims without the codes will be returned unpaid.
The rule also requires SLPs to report:
- At admission: one of the treatment plan's projected goals.
- At discharge: goal status and severity level of an expected outcome.
G-codes are not difficult to report, and NOMS will generate the corresponding G-codes for each patient entered into that system. The codes and reporting instructions can be found at ASHA's Outpatient Medicare Physician Fee Schedule page. For instructions on documentation for Medicare patients, visit our Medicare Documentation Overview page. For information about NOMS, see the supplement or our NOMS site.
Physician Quality Reporting System
Some SLPs must also participate in a second outcomes reporting system, the Physician Quality Reporting System (PQRS), or face reimbursement penalties. SLPs in private or group practice who bill Medicare Part B using their individual National Provider Identifier (NPI) on the claim form must participate in PQRS.
Implemented as a voluntary, incentive-driven system to track the quality of care and outcomes of Medicare beneficiaries with specific diagnoses, PQRS changes to a penalty-driven system in 2013. All Medicare providers, including SLPs and audiologists, who fail to report on eligible beneficiaries in 2013 will be subject to penalties in the Medicare reimbursement. Providers who fail to report eligible patients in 2013 will be subject to a 1.5% payment reduction in 2015 and increased reductions in subsequent years.
SLPs can use either of two mechanisms to satisfy PQRS requirements. The first is reporting of functional communication measures (FCMs) for stroke patients treated for one or more disorders directly related to an FCM (spoken language comprehension, spoken language expression, motor speech, reading, writing, attention, memory, and swallowing). The FCMs are the measures on which the G-codes are based. SLPs report these data through a Medicare-approved third-party registry such as NOMS, whose participants can elect to have NOMS report their measures to Medicare (see sidebar for enrollment information). A few for-profit registries also are available.
The second mechanism is to report PQRS Measure #130, documentation of current medications in the medical record. This measure can be reported directly on the Medicare claim form, and applies to all patients (regardless of diagnosis) billed for a number of CPT codes (Common Procedural Terminology, © American Medical Association), inclduing four reported by SLPS:
- 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.
- 92526 Treatment of swallowing dysfunction and/or oral function for feeding.
- 97532 Cognitive skills development.
Under Measure 130, the SLP attests on the claim form to "documenting a list of current medications to the best of his/her knowledge and ability. This list must include all prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements and must contain the medications' name, dosage, frequency and route of administration."
SLPs will see changes in 2013 reimbursement rates because of two factors: the conversion factor established by a statutory formula and changes in the "practice expense"—one of several costs factored into the value of any given procedure code—for speech-language treatment codes.
The value of each procedure code is determined by calculating three types of relative value units (RVUs) that togther make up the cost of providing the service—professional work, technical expenses (practice expense), and professional liability insurance (malpractice). The total RVUs for each service is the sum of the three components (components are adjusted for geographical differences); the RVUs for any particular CPT code are multiplied by a conversion factor to determine the corresponding fee.
In 2013, speech-language codes will be affected by the final year of a four-year phase-in of practice expense value changes, the result of updated practice cost surveys. These changes have decreased rates for many speech-language codes, mostly because the costs of operating a speech-language pathology practice are substantially less than those of a medical practice.
However, SLPs' services are now recognized as professional work due to ASHA's legislative efforts that gave SLPs Medicare provider status. Professional work RVUs do not change over time, but practice expense values fluctuate according to CMS payment formula policies.
CMS has established a 2013 conversion factor of $25.0008, a figure that is 26.5% lower than the 2012 factor. Although this rate is mandatory because of a statutory formula known as the sustainable growth rate (SGR), Congress has enacted legislation to change the factor almost every year since the SGR was implemented. Policy-watchers anticipate that Congress will once again vote to prevent this drastic cut by the end of 2012.
ASHA will post new fees for speech-language codes when congressional action is complete—or when it becomes clear that Congress will choose not to act. Check ASHA's Billing & Reimbursement website for updates.
The therapy cap—the maximum amount of combined speech-language treatment and physical therapy allowed per beneficiary—increases from $1,880 to $1,900 for 2013. In recent years, Congress has authorized an exceptions process that allows beneficiaries to exceed the cap if providers use a -KX modifier on the Medicare claim form. The 2013 rules reiterate that the current exceptions process expires Dec. 31, as does the manual medical review process implemented in October 2012 for services that exceed a $3,700 threshold.
Congress is expected to extend the manual medical review process and the inclusion of hospital outpatient department therapy services, along with the exceptions process, for 2013, until a permanent therapy payment alternative is developed
Absent congressional action, Medicare beneficiaries will be held to the cap. ASHA will continue its advocacy efforts to ensure extension of the exceptions process in 2013 while working with CMS to develop alternatives to the cap. Check ASHA's Billing & Reimbursement website for updates.
CMS will require a physician to have a face-to-face visit with a patient who needs a speech-generating device (SGD). Under current regulations, a physician ordering an SGD needs only a written evaluation of the patient signed by a certified SLP. Beginning July 1, a physician must document that a physician (or physician assistant, nurse practitioner, or clinical nurse specialist) has met with the patient within six months before the written order for the SGD. Medicare will pay approximately $17 for the visit.
The face-to-face requirement, which applies to about 150 codes (including four SGD codes) in the Health Care Common Procedure, is designed to reduce fraud, waste, and abuse. The four SGD codes are:
- E2502: Speech-generating device, digitized speech, using prerecorded messages, 8–20 minutes.
- E2506: Speech-generating device, digitized speech, using prerecorded messages, greater than 40 minutes.
- E2508: Speech-generating device, synthesized speech, required message formulation by speech and access by physical contact with the device.
- E2510: Speech-generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access).
Multiple Procedure Payment Reductions (MPPR)
The eight speech-language pathology procedures included in the 2012 MPPR policy will continue in 2013. Under this system, per-code reimbursement is decreased when multiple codes are performed for a single beneficiary in the same day. For more information on MPPR, including billing scenarios and a list of the eight codes subject to MPPR, visit ASHA's Medicare Fee Schedule Rates page.
Revised CPT Codes
The 2013 rule removed the term "physician" from three interpretation and report codes for certain endoscopic procedures. With this change, SLPs who have not performed the endoscopy—but do interpret the images—may be able to bill for their time using the following CPT codes:
- 92613, Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording; interpretation and report only.
- 92615, Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording; interpretation and report only.
- 92617 Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording; interpretation and report only.
SLPs should, however, contact their local Medicare contractors to ensure they may use the codes. An SLP who has performed the evaluation should use only the code for evaluation and may not also bill the interpretation and report code.
Additional information on the revised codes will appear in a future issue of The ASHA Leader and posted at our Revised CPT Codes page.