August 1, 2013 Departments

News in Brief: August 2013

Surgeons Perform First U.S. Pediatric ABI Implant

Surgeons at the University of North Carolina Hospitals recently performed the first pediatric auditory brainstem implant in the United States. Three-year-old Grayson Clamp of Charlotte, N.C., who was born without cochlear nerves and lacked the ability to hear, received the implant as part of an FDA-approved investigational trial.

The trial, approved by the FDA in January 2013, is sponsored by the House Research Institute and its new Koch Center for Hearing Restoration, in partnership with Children's Hospital Los Angeles. The ABI was developed at House and is the world's first successful prosthetic hearing device to stimulate neurons directly at the human brain stem, entirely bypassing the inner ear and hearing nerve. Since the procedure began, more than 1,000 adults worldwide have received the ABI. The clinical trial is part of an international consortium with the University of Verona in Italy, where ABI already is a successful treatment for children.

ABI implantation involves making an incision behind the ear, and entering the cranium through a small window of bone to confirm the auditory nerve's absence. A small electrode is placed on the ventricle floor, covering the cochlear nucleus. A cable extends from the electrode, through the bone, and coils just beneath the skin to hook up to an external receiver. The device transmits sound signals from the ear directly to the cochlear nucleus, allowing the patient to hear.

Craig Buchman, professor of otolaryngology/head and neck surgery, and Matthew Ewend, chair of the Department of Neurosurgery, performed the surgery. "We're bringing the potential for hearing to a child who can't hear and had no other options," Buchman said in a UNC video interview. "Seeing him respond, that had a lot of feelings for me. I felt like there was a potential that we were effectively changing the world in some ways."

See the moment the implant was turned on at UNC Healthcare's website.

MedPAC Report Calls for Lower Therapy Caps, More Frequent Physician Reviews

A recent report by a federal advisory committee includes several recommendations that may impede Medicare beneficiaries' access to speech-language treatment and other therapy services.

The Medicare Payment Advisory Commission, an independent agency that advises Congress on Medicare reimbursement policy, access to care, quality of care and other issues affecting Medicare, submitted "Mandated Report: Improving Medicare's Payment System for Outpatient Therapy Services [PDF]" in June.

On reimbursement-related issues, the MedPAC report calls on Congress and the Centers for Medicare and Medicaid Services to:

  • Reduce the combined speech-language pathology/physical therapy cap to $1,270 for 2014 and permanently include hospital therapy services in the therapy cap.
  • Streamline manual medical review of claims that exceed the cap by requiring reviewers to notify providers when they receive documents, require a 10-day response time, and centralize and limit the number of review sites.
  • Increase the frequency of physician certification for therapy plans of care from every 90 days to every 45 days.
  • Increase scrutiny of therapy services delivered in geographic areas with high rates of attempted Medicare fraud rather than conduct widespread provider reviews.

The report also responds to the mandate in the Middle Class Tax Relief and Job Creation Act of 2012 that MedPAC consider a payment system based on the patient's condition, and to examine private sector initiatives regarding therapy services. It recommends that Congress and CMS:

  • Gather more clinical data in a streamlined, standardized assessment tool that includes information on functional limitations and status, patient demographics, diagnoses, medications, and surgery, to measure the impact of all therapy services.
  • For long-term payment reform, use the data to develop an episode-based, bundled payment system with reimbursement influenced by a patient's functional improvement.
  • Improve use of diagnosis codes.
  • Set national guidelines and edits on the number of timed codes billed per day per beneficiary.

The report fulfills the annual requirement that MedPAC advise Congress on Medicare payment across all services. Chapter 9 of the report specifically addresses speech-language pathology, physical therapy and occupational therapy. Congress must act on the recommendations for the changes to become effective. ASHA has been working with MedPAC to ensure that speech-language pathology services are appropriately recognized and addressed.

Lisa Satterfield, MS, CCC-A, is ASHA director of health care regulatory advocacy.

Submit Your Nomination for 2014 Safe-In-Sound Awards

Nominations are being accepted for the 2014 Safe-in-Sound Excellence in Hearing Loss Prevention Awards™. The awards, given by The National Institute for Occupational Safety and Health in partnership with the National Hearing Conservation Association, recognize effective practices in hearing loss prevention. The deadline for self-nominations is Sept. 6. For more information, visit Safe-in-Sound or e-mail@safeinsound.us.

UnitedHealthcare Now Covers SLPs' Cog Rehab Treatment

UnitedHealthcare has revised a policy that broke with federal coding guidelines in denying coverage for cognitive rehabilitation provided by a speech-language pathologist.

UHC was refusing to reimburse SLPs' claims for CPT code 97532 (Common Procedural Terminology, © American Medical Association). The code describes "Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes."

The UHC action comes in response to a complaint ASHA filed over UHC's March 2013 bulletin revision that stated, "In alignment with CMS [Centers for Medicare and Medicaid Services] coding guidelines ... UHC will not reimburse speech-language pathologists for code 97532." This policy, however, conflicts with CMS guidelines, which cover cognitive rehabilitation—specifically CPT 97532—when provided by SLPs. ASHA provided supporting documentation:

  • National Correct Coding Initiative Policy Manual wording that acknowledges that SLPs perform 97532.
  • The CMS Program Memorandum AB-00-14 (March 2000) that states an SLP can use 97532.
  • ASHA scope of practice information about the role SLPs play in cognitive rehabilitation.

Based on this information, ASHA concluded that UHC was denying a covered treatment to beneficiaries based on inaccurate interpretation of CMS policy, and urged UHC to include coverage of 97532 provided by SLPs.

ASHA copied the letter to state insurance departments in states in which UHC was denying the coverage. After receiving the letter, the Washington State Office of the Insurance Commissioner requested that UHC respond to ASHA within 15 business days. The insurance commissioner's office asked UHC to provide specific information in its response, which the state would use to "report the complaint data to the National Association of Insurance Commissioners."

UHC responded within the requested time, noting that its investigation confirmed that the policy was incorrect. UHC proceeded to revise its policy, noting that it would no longer deny 97532 when reported by an SLP, effective for claims for service provided on or after Feb. 24, 2013, and published a correction article in its July 2013 Network Bulletin.

Consumers and providers are advised to resubmit denied claims to UHC. For help resubmitting denied claims or for more information, contact Janet McCarty at jmccarty@asha.org.  

Janet McCarty, MEd, CCC-SLP, is ASHA private health plans advisor.

New FAQs for ICD-10 Billing

As the date for implementing the new ICD codes approaches, what do providers need to know about submitting claims for services provided on days immediately surrounding that date—Oct. 1, 2014?

The International Classification of Diseases is used to report medical diagnoses and inpatient procedures. The 10th edition differs substantially from the current ICD-9.

The Centers for Medicare and Medicaid Services recently posted three new FAQs related to submitting claims on or around the Oct. 1, 2014, compliance date.

The three new FAQs on ICD-10 billing discuss:

  • How to report ICD-10 codes on claims when the dates of service span from prior to Oct. 1, 2014, to on or after that date (#8246).
  • Compliance with the Health Insurance Portability and Accountability Act for submission with an ICD-9 code for a date of service after Oct. 1, 2014 (#8248).
  • The need to report ICD-9 codes after the Oct. 1, 2014, compliance date for ICD-10 (#8252).

McLaughlin to Head Special Education Research Center

Joan McLaughlin, deputy commissioner of the National Center for Special Education Research of the Institute of Education Sciences since 2009, became acting commissioner July 1. As deputy commissioner, she led the special education research and research training programs. She also served as the program officer for the early intervention and early learning in special education grant program.

Before joining IES, McLaughlin spent 16 years in the Education and Family Services Area at Abt Associates, Inc., where she was principal investigator or project director for evaluations of federal education, food assistance and early childhood programs.

McLaughlin replaces Deborah Speece, who is leaving after two years to become associate dean of research and faculty development in the School of Education at Virginia Commonwealth University.

NCSER, one of four centers in the Institute of Education Sciences, supports a comprehensive program of special education research designed to expand the knowledge and understanding of infants, toddlers and children with disabilities or at risk for disabilities. The center also funds research training programs.

For more information, visit the NCSER website.

Loan Forgiveness Passes in Two States—But Without Funding

New laws in Texas and Mississippi authorize loan forgiveness programs to recruit speech-language pathologists and audiologists to underserved public schools. Although neither measure has money attached to it, state association leaders remain optimistic about their chances to win state funding for programs. Check out the states' stories—and association leaders' advocacy tips—at The ASHA Leader.

Rehab Corp. Must Repay $3 Million in Improper Medicare Claims

A federal investigation that requires a New Jersey rehabilitation corporation to repay more than $3 million underscores the importance of correct billing and documentation of Medicare outpatient therapy services—and illustrates the government's increased scrutiny of Medicare transactions.

The investigation, conducted by the Office of the Inspector General of the Department of Health and Human Services, found that 83 of 100 claims sampled were improperly submitted and reimbursed. None of the improper claims involved speech-language pathology services.

According to the OIG's report [PDF], Spectrum Rehabilitation must return $3,112,501 for physical and occupational therapy services wrongfully claimed and reimbursed in 2009 and 2010. Investigators cited records that violated requirements for:

  • Physician certification—Certifications lacked dates or did not meet the 30-day initial certification requirement or 90-day recertification requirement.
  • Treatment notes—Records lacked treatment notes or failed to document treatment time.
  • Providers—The physical or occupational therapist listed as the rendering provider did not perform or supervise the treatment. Non-enrolled providers performed services that were billed under enrolled providers' identification.
  • Medical necessity—Services were not medically necessary or lacked documentation to support medical necessity.
  • Plan of care—Documents lacked information on type, amount, frequency and duration of therapy; diagnosis; and anticipated goals.

The OIG calculated the repayment based on the 83 improper claims, and applied the calculation to the 40,129 claims submitted in the audited time period. OIG further recommended that the provider strengthen its Medicare documentation policies and procedures and acquire a better understanding of Medicare reimbursement requirements.


  

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