Physician Offices and Groups-Coverage Guidance

(Known under Medicare as billing "Incident to Physicians' Services")

Unlike physical therapists and occupational therapists, speech-language pathologists were not recognized as providers who could directly bill the Medicare program until July 16, 2008, when the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 was passed. MIPPA included a provision that allows speech-language pathologists in private practice to directly bill the Medicare program effective July 1, 2009. For more information go to Medicare & Speech-Language Pathologists in Private Practice.

Speech-language pathologists enrolled in the Medicare program are no longer subject to the "incident to" rule, may see patients without the direct supervision of a physician, and should use their own Medicare numbers when submitting reimbursement for their services, even if they work in a physician office/group.

Speech-language pathologists who do not wish to be enrolled in the Medicare program may still provide services to Medicare beneficiaries by contracting with a physician's office and following the "incident to" rules, as outlined below. The Medicare program allows "auxiliary personnel" (non-physician employees and independent contractors) to bill under a physician's provider number. This billing practice is permissible as incident to physician services. In order for the services to be billable as incident to:

• A physician must be present in the office suite, and
• A physician in the office must have already seen the patient and will actively participate in the management of the course of treatment. (See Medicare Benefit Policy Manual, Chapter 15, Section 230.5 [PDF])

Some steps to consider in contracting with a physicians office include:

1. Contacting physicians' offices to see if there is an interest to bring a speech-language pathologist into the practice.
   • Medicare does not place limitations on the type of physician practice with which a speech-language pathologist may affiliate.
2. Negotiating a contract with the physician practice
   • Medicare does not regulate the terms of payment between a physician and its employees.
   • The SLP should negotiate for the most favorable terms. A logical starting point for negotiations is the Medicare reimbursement rate for the speech-language pathology services, and the average private insurance payment per evaluation and per treatment sessions.
     • Medicare payment rates
     • Additional information on negotiating contracts can be found in an ASHA publication " Negotiating Health Care Contracts and Calculating Fees - A Guide for Speech language Pathologists and Audiologists "
     • Stark Laws - Physician self- referral laws do not apply to services rendered by employees or contractors of the physician practice as long as incident to a physician service rules are adhered to. Additional information on the kick-back and Stark rules can be found in the Medicare Handbook for Speech-Language Pathologists , a for-sale product.
3. Understand all Medicare rules and regulations
   
   • CMS policies can be found on their Web site . Many CMS intermediaries and carriers have local coverage determinations specific to dysphagia or speech-language pathology services. These local determinations can be found on the intermediaries' or carriers' websites.
4. Billing Medicare
   • Speech-language pathology services are billed in the same manner as physician services using the appropriate CPT and diagnostic (ICD) code.
   • Speech-language pathologists should also be aware of any Correct Coding Initiative (CCI) edit, which would preclude certain CPT code pairs being billed together on the same day. Learn more about CCI edits .

CMS affirmed that current qualification and training standards for therapists under Medicare apply to services rendered by employees or contractors of physicians. CMS adopted a new regulation, 42 CFR 410.62, "Outpatient speech-language pathology services: Conditions and exclusions" that references speech-language pathology qualifications for home health agency conditions of participation (42 CFR 484.4):

Speech-language pathologist . A person who:

1. Meets the education and experience requirements for a Certificate of Clinical Competence in speech-language pathology granted by the American Speech-Language-Hearing Association; or
2. Meets the educational requirements for certification and is in the process of accumulating the supervised experience required for certification.

Medicare rules require that a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) be in the office suite when therapy services are rendered. In States that authorize physicians, PAs, NPs, and CNSs to provide one or more therapy services, they need not meet the training requirements applicable to therapists.

Again, only speech-language pathologists in physician offices who are not enrolled as Medicare providers are subject to the "incident to physicians' services" rule. Speech-language pathologists who do not wish to contract with a physician's office may bill Medicare directly by becoming a Medicare provider and establishing their own private practice.

For additional information on Medicare billing and coverage, contact ASHA's Health Care Economics and Advocacy Team at reimbursement@asha.org.