Physician Offices and Groups-Coverage Guidance
(Known under Medicare as billing "Incident to
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
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
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:
Some steps to consider in contracting with a physicians office
Contacting physicians' offices to see if there is
an interest to bring a speech-language pathologist into the
- Medicare does not place limitations on the type of
physician practice with which a speech-language pathologist
Negotiating a contract with the physician
- 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.
- 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.
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.
- 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
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):
. A person who:
- Meets the education and experience requirements for a
Certificate of Clinical Competence in speech-language pathology
granted by the American Speech-Language-Hearing Association;
- 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
For additional information on Medicare billing and coverage,
contact ASHA's Health Care Economics and Advocacy Team at