Medicare and Speech-Language Pathologists in Private Practice

Billing and Coding

ASHA Resources

CMS Resources

There are a number of regulations, guidelines, and policies that must be understood before billing for Medicare services. This page will provide important billing and coding information relevant to speech-language pathology services and will guide you to additional resources.

Billing Medicare

Medicare billing is coordinated through your local Medicare contractor, however, the standard form used for submitting claims is called the CMS 1500 Health Insurance Claim Form [PDF]. For step-by-step instructions on completing and processing the CMS 1500 form, go to Chapter 26 of the Medicare Claims Processing Manual [PDF].

There are two ways claims may be submitted:

Electronically - Electronic claims are paid faster and can help cut down on the administrative burden for both you and Medicare. To bill electronically, your practice must meet all required Health Insurance Portability & Accountability Act (HIPAA) standards.
By Paper - Medicare providers must meet certain requirements to submit paper claims.

Reimbursement

Speech-language pathology services under Medicare Part B have reimbursement rates established by the Medicare Physician Fee Schedule regardless of provider setting. Payment is determined by the fee associated with a specific procedure code (see Coding for Reimbursement) in those settings. The fee schedule is updated annually.

Payments for outpatient therapy services are subject to a targeted medical review threshold of $3,000. There is one targeted review threshold of $3,000 for occupational therapy and a second threshold of $3,000 for speech-language pathology and physical therapy combined. There is also a trigger of $2,040, at which point the KX modifier must be included on the claim to demonstrate continued medical need for services.

Coding for Reimbursement

There are three major coding systems used when submitting claims for reimbursement by Medicare. Below are links to speech-language pathology related codes compiled from each of the major coding systems:

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) - used to report diagnoses and disorders
Current Procedural Terminology (CPT) - used to report procedures or services provided

Model Superbill [DOC] (comprehensive list that also contains codes not reimbursed by Medicare)
ASHA's Medicare Fee Schedule for Speech-Language Pathologists (contains only those codes reimbursed by Medicare)

Healthcare Common Procedure Coding System (HCPCS) - used to report supplies, equipment, and devices provided

Medicare Coding Rules

Medicare has very specific rules regarding coverage of certain codes and services. ASHA has compiled Medicare coding rules related to speech-language pathology services, however, you should also be aware of local coverage determinations (LCDs) from Medicare contractors that are specific to your locality. To find LCDs, go to the Medicare Coverage Database and search for "Local Coverage Documents" by keyword and locality.

Medicare Benefit Policy Manual

The Medicare Benefit Policy Manual provides general coverage rules and regulations for providers of Medicare services. Specifically, Chapter 15, Section 220-230.6 [PDF] of the manual addresses the rules and regulations related to therapy services (speech-language pathology, physical therapy, and occupational therapy) provided in an outpatient setting.