Medicare and Speech-Language Pathologists in Private Practice Frequently Asked Questions

What changed that will allow speech-language pathologists to bill Medicare?

Previously, the Medicare statute allowed physical therapists and occupational therapists to obtain Medicare provider numbers but not speech-language pathologists. ASHA worked earnestly to gain Congressional support to include this provision in a Medicare bill. Congress passed the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) on July 16, 2008, that included the Medicare speech-language pathology private practice provision, overriding President Bush's veto.

Why do I have to wait before I can bill Medicare?

The effective date of the speech-language pathology relevant section of MIPPA is July 1, 2009. The delayed implementation gives the Centers for Medicare and Medicaid Services (CMS) time to develop and implement the necessary regulations. In addition, the agency must make certain system changes to allow for private practice speech-language pathologists enrollment. This process is anticipated to take close to a year.

When can I enroll as a provider in the Medicare program?

Speech-language pathologists may begin enrolling on, and not before, June 2, 2009. Learn more about the enrollment process.

Can I start seeing Medicare patients now and hold my claims until next year?

No. The law specifically states that the provision is effective for services provided on or after July 1, 2009. Providing services now and holding claims is not permitted.

Does this create three caps or do we still share one with PTs?

The legislation did not alter the two-cap design (i.e., a combined cap for physical therapy and speech-language pathology and a separate cap for occupational therapy are still in place). This combined cap does not present a critical restriction because the exceptions process allows speech-language pathology services to surpass the cap as long as documentation shows that the services are reasonable and necessary.

What can I do now to prepare to be a Medicare provider?

As a first step, speech-language pathologists interested in enrolling in the Medicare program should obtain a National Provider Identifier (NPI), if they have not already done so. CMS offers more information on the NPI, including a general overview and how to apply. For more information on preparing to become a provider, go to ASHA's section on Medicare & Speech-Language Pathologists in Private Practice.

How do I find out how much Medicare pays for different procedures?

Speech-language pathologists in private practice will be reimbursed based on the Medicare Physician Fee Schedule (MPFS). ASHA's annual analysis of the MPFS rules [PDF] provides information on procedures specific to speech-language pathologists related to the Medicare fee schedule.

Do I have to have an office to bill Medicare?

The Centers for Medicare and Medicaid Services (CMS) will be developing regulations governing Medicare billing practices for speech-language pathologists in private practice. We will provide more information on Medicare requirements once they become available.

Will I be able to bill Medicare for private practice speech-language pathology services that I provide to Medicare patients in a hospital, SNF, or home health agency?

No. Those services are bundled into the prospective payment to the institution or paid to the home health agency per episode of care. Private practitioners can contract with hospitals, SNFs, or home health agencies, but the facilities are required to bill Medicare directly.

Can I be in a partnership with a physical therapist or occupational therapist?

The conditions of participation for speech-language pathologists in private practice will be outlined in the regulations. Issues, such as the acceptable types of practices and settings, will be addressed by CMS in the regulations. ASHA will provide information once it becomes available.

Will I need a physician's order to see a Medicare patient?

The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 allows speech-language pathologists to enroll as a Medicare provider. As always, a physician order or referral is not required, although the physician must approve the plan of care within 30 days and periodically thereafter. These Medicare required physician services can be rendered by a nurse practitioner or a physician assistant if consistent with state and local laws. Please visit ASHA's Web site for additional information on Medicare oversight rules that are contained in the Medicare Benefit Policy Manual.

I am dually certified and would like to enroll in Medicare as both an audiologist and a speech-language pathologist. How should I apply?

Dually certified Audiologists/Speech-Language Pathologists must submit a separate enrollment application for each specialty if you want to enroll as more than one non-physician specialty type. You will use the same NPI number for both applications.

Introduction | Enrollment Process | Billing & Coding

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