ASHA's Medicare Fee Schedule provides a list of CPT codes with short descriptors and associated national rates for speech-language pathology services. For precise payment rates based on locality, go to the CMS website.
Clinical fellows (CFs) practicing in States that grant CFs temporary or provisional licensure are fully qualified to provide services according to Medicare regulations. However, in states without such licensure, Medicare treats clinical fellows as graduate students requiring "in the room" supervision. For more information, see Medicare Coverage of Students.
Services of speech-language pathology assistants are not recognized for Medicare coverage. Services provided by speech-language pathology assistants, even if they are licensed to provide services in their states, will be considered unskilled services and denied as not reasonable and necessary if they are billed as therapy services. Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.
A physician referral is not required for Medicare patients. The Medicare program allows the plan of care to be established by the physician or the speech-language pathologist. If the plan of care is written by the speech-language pathologist, it must be certified by the patient's physician within 30 days. For outpatient services, the plan of care must be recertified by the physician every 90 days from the initiation of treatment or when there is a significant modification to the plan. The physician must review the plan of care every 60 days for home health agencies and Comprehensive Outpatient Rehabilitation Facilities. The physician or speech-language pathologist can make changes in the plan of care. The speech-language pathologist may not significantly alter a plan of care without recertification from the physician.
Medicare requirements for a plan of care are set forth in the Medicare Benefit Policy Manual, Chapter 15, Section 220.1.2 [PDF]. See also: Overview of Documentation for Medicare Outpatient Therapy Services
Clinicians who wish to see Medicare beneficiaries must enroll in the Medicare program. The quickest way to do it is through Medicare's online enrollment system, though paper applications are also available. For more information, go to ASHA's web page on Medicare & SLPs in Private Practice.
Non-institutional providers and suppliers use the CMS 1500 form to bill Medicare Part B services, Medicaid, and private health plans. Diagnosis codes are inserted in Sections 21 and 24E. CPT codes are inserted in Section 24D. You may print sample copies [PDF] through the CMS website or obtain copies from your local Medicare carrier, local printing companies, or the Government Printing Office.
Yes, however, speech-language pathology services are billed to Medicare by the SNF for Part A and Part B residents. A contract specifying payment terms should be executed between the speech-language pathologists and the facility. See also: Medicare SNF Prospective Payment System
Different facilities or agencies have different requirements for how services are to be documented (e.g., SOAP notes, narrative) and where notes are to be maintained (e.g., carbonless copies, writing notes directly in the patient's chart, electronic medical record.)
Clinicians must consider the needs of the audience for which the documentation is intended. Oftentimes, a variety of related professionals and claims reviewers will read the assessment report, treatment plans, and discharge summaries, so the clinician needs to ensure that what thy write can be understood by an audience of varying backgrounds and experience.
Payers may have documentation requirements of their own, including the information they want to see when reviewing a claim and the timelines in which documentation must be submitted. Typically, health plans are instructed by law to initially request only the minimum information necessary to pay a claim. See also: Overview of Documentation for Medicare Outpatient Therapy Services
Medicare policy specifically allows speech-language pathologists to use 97129 (cognitive function intervention, initial 15 minutes) and 97130 (cognitive function intervention, each additional 15 minutes) for treatment of cognitive disorders, but notes that either code 92507 or 97129/97130 could be used, but not both for the same treatment. Additionally, officials at the Centers for Medicare and Medicaid services do not support the use of other physical medicine codes because the vignettes (examples of the procedures performed with a typical patient) used reflect physical therapy or occupational therapy. The officials contend that procedures such as speech-language pathology treatment (92507) and dysphagia treatment (92526) are bundled codes and encompass all elements of a therapy service. CPT code 92507 (speech-language treatment) is very comprehensive and generally includes all components of treatment. Using a 92000 code in combination with a 97000 code may constitute unbundling of codes, and is not allowed. Unbundling is when you code one component of a treatment separately when that component is already captured under a more comprehensive code that you are also using. See also: Use of Physical Medicine Codes
Go to National Correct Coding Initiative (NCCI) Edits for details, including a list of Correct Coding Initiative (CCI) edits for speech-language pathology codes.
CMS uses this automated edit system to control specific code pairs that can be reported on the same day. The National Correct Coding Initiative (NCCI or, more commonly, CCI) has been in place since January 1, 1996, and is updated quarterly. The goals of CCI are to eliminate "mutually exclusive" code pairings and codes considered to be components of more comprehensive services or otherwise inappropriate to be delivered to the same patient on the same day.
The Medicare fiscal intermediary should be contacted to determine if a local policy exists regarding treatment during a holiday. There is a somewhat relevant instruction about breaks in rehabilitation service from the federal Medicare program. The Centers for Medicare and Medicaid Services (CMS) issued guidance ( Federal Register , 7/30/99, p. 41670) for maintaining coverage in a skilled nursing facility (SNF) that requires receipt of skilled services at least five days per week: "...the Medicare program does not specify in regulations or guidelines an official list of holidays or other specific occasions that a facility may observe as breaks in rehabilitation services...The facility itself must judge whether a brief, temporary pause in the delivery of therapy services would adversely affect the resident's condition." However, this guidance is not definitive because it was in response to situations where a SNF resident initiated a brief absence to attend an event with family or friends. It also does not respond to a specific Plan of Care that calls for 5 treatments per week.
A provider cannot charge Medicare a greater fee then their normal fee for a service, thus may not accept the higher fee. The Medicare payment will be the lower of the actual charge or the fee schedule allowance. If the reimbursement is from a private insurance company the speech-language pathologist should refer to the contract between the provider and the health plan. If no such contract exists, the professional should contact the payer for clarification.