Medicare Coverage of Students & Clinical Fellows: Audiology

Medicare law describes the professions that are qualified to provide services to beneficiaries. The practitioners must be licensed by the state or have a credential such as the ASHA Certificate of Clinical Competence in those states without licensure.[1]Medicare does allow billable interactions between students and beneficiaries but these are limited.

Clinical Fellows

The student policy described below does not apply to Clinical Fellows practicing in States that grant Clinical Fellows temporary or provisional licensure; such licensed practitioners are fully qualified according to Medicare regulations. However, in States without such licensure, Medicare treats clinical fellows as graduate students requiring "in the room" supervision. Go to ASHA's State Specific Licensing and Regulatory Resources for more information on licensing laws in your state.

Students

Part A Patients

The only policy issued regarding student services for Medicare Part A beneficiaries relates to those provided in skilled nursing facilities (SNFs).

The level of supervision of students required for Part A residents in SNFs is specified by the Centers for Medicare and Medicaid Services (CMS). CMS revised the regulations for the SNF prospective payment system in the Federal Register of July 30, 1999, (Vol. 64, No. 146, p. 41661).

A therapy student who is participating in field experience must also be under "line-of-sight" level of supervision of the professional therapist.

As of October 1, 2010 "line-of-sight" means "the supervising therapist/assistant shall not be treating or supervising other individuals and he/she is able to immediately intervene/assist the student as needed and the student and resident are both under line of sight supervision." We interpret this to mean that the supervising speech-language pathologist would be able to work on documentation while complying with the line of sight requirements.

Other Part A providers such as rehabilitation agencies and home health agencies should refer to Part B requirements for student supervision requirements and, as always, state regulations.

Part B Patients

ASHA received a formal response to concerns raised when some Medicare carriers refused to acknowledge a Medicare program clarification sent to ASHA (November 9, 2001) relating to payment involving therapy students for Part B services. The CMS policy is found in the Medicare Benefit Policy Manual, Chapter 15, Section 230.B.1 [PDF].

Section 15/230.B.1 of the Medicare Benefit Policy Manual "manualizes" Program Memorandum (PM) AB-01-56, "Questions and Answers Regarding Payment for the Services of Therapy Students Under Part B of Medicare." Section 15/230.B.1 indicates that a therapist may bill and be paid for the provision of services when the "qualified practitioner is present and in the room for the entire session. "The student may participate "in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment." Section 15/230.B.1 further states that billing and payment are appropriate when the "qualified practitioner is present in the room guiding the student in service delivery when the therapy student...(is) participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time."

These rules apply to both individual and group therapy. One-to-one patient contact is not necessary for group therapy even though constant attendance is required.

This student policy does not apply to clinical fellows practicing in States that grant clinical fellows temporary or provisional licensure (as discussed above). However, in States without such licensure, Medicare treats clinical fellows as graduate students requiring "in the room" supervision.

Part B – Additional Guidance Regarding Audiology Students

A November 9, 2001, letter was received by ASHA from Terrence L. Kay, Director of the Division of Practitioner and Ambulatory Care in the CMS Center for Medicare Management, clarified the student issue with specific regard to speech-language pathology and audiology students.

The letter states that Medicare requires that the qualified practitioner be "in the room guiding the student in service delivery when the graduate student is participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time." Mr. Kay's letter also states, "The qualified practitioner is responsible for the services and as such, signs all documentation." He added parenthetically that the student may also sign the documentation if desired.

Mr. Kay included two scenarios, one for audiology services and one for speech-language pathology services, to illustrate Medicare Part B billable services. They are:

• An audiologist is assessing the hearing of a Medicare Part B beneficiary who was referred because of hearing loss and vertigo. The graduate student participates in conducting the pure tone and speech audiometry. The audiologist is in the room and engaged only in that patient’s assessment at all times.
• A speech-language pathologist is seeing a Medicare Part B beneficiary who has aphasia. The speech-language pathologist, with the graduate student's participation, develops a treatment plan for the session and both see the patient with the speech-language pathologist controlling the services rendered. The speech-language pathologist is in the room and engaged only in that patient's treatment at all times.

For further information or additional information, contact Mark Kander at 800-498-2071, ext. 4669 or mkander@asha.org.

[1] In states without licensure, the individual must have successfully completed 350 clock hours of supervised clinical practicum, performed not less than nine months of supervised full-time audiological or speech-language pathology services after obtaining a master's or doctoral degree in audiology, speech-language pathology, or a related field, and successfully completed a national examination in audiology or speech-language pathology.