This is the final module in speech-language pathology for the health care reimbursement and coding online education series. It addresses general aspects of third party payment.
This module starts with a recap of the two major coding systems. The ICD-9-CM codes (or the ICD-10-CM, as of October 1, 2015) describe the problem you diagnosed or is being addressed in therapy. It is coordinated and maintained by the U.S. Department of Health and Human Services. The CPT codes describe the procedures you perform and is updated, copyrighted, and published by the American Medical Association.
Let's review the principles of diagnostic coding and then put them into practice. Coding to the highest degree of certainty means using a diagnostic code of 5 digits, if possible. The ICD-9-CM codebook will indicate when you have to use additional digits.
The primary ICD-9-CM code is for the diagnosis, condition or problem chiefly responsible for the services provided. If results of diagnostic testing are NORMAL, code signs or symptoms to report the reason for test/procedure and explain the normal result in the report. Disease or diagnosis codes should support or coordinate with the procedure codes and vice versa. These same principles will apply to ICD-10-CM, once implemented.
These rules were established by Medicare, but many other payers adopt the same rules. The rules are:
Again, these same principles will apply to ICD-10-CM once implemented.
The combination of a Diagnostic code (or ICD-9-CM code or ICD-10-CM) with a Procedural code (or CPT code) must be logical. Most payers have lists of which diagnostic codes make sense with which procedure codes. For example, if the diagnostic code was fractured hip, providing speech-language pathology services doesn't make much sense. But, if the patient with a broken hip also has a diagnosis of stroke (434.91), then SLP services (such as 92507) are logical.
Refer to Medicare's National Correct Coding Initiative (or CCI Edits) to determine which procedures may be delivered and billable to the same patient on the same day. The numbers listed here are CPT modifiers that may be accepted by payers. The facility where you work will explain how they want to use these modifiers on procedure codes.
Medicare coding requires speech-language pathologists to use a GN modifier so that the contractor includes the cost of the service in the therapy cap.
Medicare has four distinct parts:
Medicaid was created to provide access to health care for people living in poverty. Private insurance is the kind of insurance most working Americans have as part of their employee benefits. Companies like Blue Cross Blue Shield, Aetna, and Humana offer health insurance for private citizens. They also administer many employer health plans. A preferred provider organization allows patients to see any health care professional (such as an audiologist) without a referral, but limits access to a panel of health care providers or pays less for those outside the panel network. Health maintenance organizations require the patient's care to be coordinated through one primary care physician. These types of plans often have special rules like obtaining pre-authorization before services are rendered. Health insurance exchanges, established as a result of the Patient Protection and Affordable Care Act, or ACA, are a one stop market place for affordable health insurance for consumers and small employers. Exchanges are run by the state or federal government. Accountable care organizations are designed to be patient-centered and to network physicians, hospitals, and other health care professionals with the patients and each other for partnering in making care decisions. Out-of-pocket payment occurs when a health plan does not cover the service or the patient does not have health insurance.
Private insurance payers often base their inpatient payment on Medicare's diagnosis-related group (or DRG) prospective payment system and their outpatient payment schedule on the Medicare Physician Fee Schedule. However, there is no rule for payers to follow, so reimbursement methodology will vary among payers.
In most inpatient settings (such as hospitals and skilled nursing facilities) the payer pays on a per-case or per-day basis. This means that regardless of the number of services provided, the amount the facility receives will not change. In most outpatient settings, the payment is per procedure. Accountable care organizations will have additional shared savings arrangements to drive efficiency. Each of these settings has rules and regulations you'll learn if you work in that setting.
Four new evaluation codes for fluency, speech, language, and voice disorders were recently created, replacing CPT code 92506, which was a single code that captured a broad range of evaluations related to speech-language pathology services. This was a significant coding change for SLPs.
We will now apply coding and documentation concepts reviewed in earlier modules to real-life scenarios. Here is the first scenario for you to consider. You have a 4-year-old male referred by the pediatrician for an evaluation of fluency skills. The referring ICD-9-CM (or diagnosis) code is 315.35 childhood onset fluency disorder. Your evaluation indicates normal and age-appropriate fluency behavior. During the evaluation you screened articulation and language, administered a fluency test, completed a fluency checklist, performed an oral motor exam, and screened hearing.
Here is your first quiz. What procedure codes would you select if you:
The answer is: You charge only ONE code (92521) for the evaluation of fluency. The articulation, language and hearing screenings are part of this comprehensive fluency evaluation.
Now it's time for an ICD-9-CM quiz for the same scenario. Remember, the findings from the evaluation were normal. What diagnosis codes do you select:
If the results indicate normal fluency you would code the signs so that you are reporting the reason for the evaluation. However, you will explain that the results are normal. In other words, you would choose 315.35 (i.e., childhood onset fluency disorder).
In this scenario you are seeing a 5-year old girl for an articulation and language evaluation. Objective evaluation measures reveal:
Which diagnosis code do you choose?
The answer is to use both 315.39 and 315.31. Remember you code to the highest degree of medical certainty and you are not using the NOS or NEC codes. Also, first list the diagnosis or disorder that you will be primarily focusing followed by any other diagnoses or related medical conditions.
Some SLPs say that they have parents or patients who want them to use a specific code so that their health plan will cover the therapy. Would you use 784.59 in this case?
In other words, do you change the code to speech disorder due to organic lesion instead of developmental articulation disorder so therapy will be paid by insurance. Or, do you explain to the parents that you understand their predicament but billing for an inappropriate diagnosis code to receive payment is unethical and illegal?
The answer is that you explain to the parents that you understand their predicament but billing for an inappropriate diagnosis code to receive payment is unethical and illegal. Never misrepresent the service that was provided in order to receive reimbursement or for your patient's convenience
Here's another scenario:
A 65 year-old female came to the emergency room with an angina attack (ICD-9-CM 413.9). She was not admitted to the inpatient unit but was admitted to the hospital's observation unit for 24-hour observation. This is considered an outpatient admission. Prior to discharge a nurse noted that the patient was coughing during meals. A Clinical swallow evaluation is ordered. Findings from the evaluation suggested oral and pharyngeal dysphagia, ICD-9-CM 787.22. An instrumental assessment of swallowing was ordered but could not be completed prior to her discharge home. It was scheduled for the next day.
In this scenario what diagnostic code should you use?
In this scenario you code ICD-9 787.22 since oropharyngeal dysphagia is the reason for your clinical bedside exam. The primary ICD-9-CM code is for the diagnosis, condition or problem chiefly responsible for the services provided. Disease or diagnosis codes should support or coordinate with the procedure codes and vice versa
In this scenario the instrumental exam reveals normal oral phase but the patient has reduced laryngeal elevation with residue in the pyriform sinuses, with aspiration after the swallow.
Following the instrumental assessment, do you:
In this case you would change the code to pharyngeal 787.23. As a result of your examination, you find the patient has problems only in the pharyngeal phase of the swallow.
You need to differentiate the various swallowing examination codes for this question, "What are the procedure codes?"
You may use the link to find a list of CPT codes to assist with your answer.
The clinical (i.e., beside) examination is 92610. If you performed a modified barium swallow, the code is 92611. If you performed the FEES® (you passed the scope and performed the analysis) you code 92612. For the modified barium swallow study, the radiologist will also bill for a procedure code. Sometimes, a physician will interpret the FEES and submit a report. In this case, the physician will bill a separate and different procedure code.
Here is a scenario where you have a 75 year-old female who travels 3 hours to the nearest outpatient speech and hearing clinic. Her payment source is Medicare. The Patient presents with dysphonia (ICD-9 code 784.42) and is referred by physician for voice evaluation (CPT 92524) and treatment (CPT 92507).
You need to select the codes used in this instance: Would it be ICD-9 784.42 for dysphonia and CPT 92524 for the evaluation of voice? In addition, should you code CPT 92507 for your first session of speech therapy to address the dysphonia? Or, should you code ICD-9 784.42 for dysphonia and CPT 92524 for the evaluation of voice? If you schedule your patient to return the next day for therapy because you cannot bill the same patient in the same day do you code for both an evaluation (CPT 92524) and speech therapy (CPT 92507)?
This question concerns private health plans which today are usually managed care organizations (MCOS) such as preferred provider organizations (PPOs). It is crucial to know the payer's identity and what the payer's particular guidelines are before seeing your patient? The patient should have this information in their health insurance contract or they can contact the MCO before you schedule the appointment.
Some facilities will have specific forms for billing. You may or may not even see the ICD-9-CM and CPT codes on the form you complete. For example, the hospital may rely on their coders to report the diagnostic and procedural codes. Nevertheless, it is your professional responsibility to ensure the correct codes are reported. You should meet with the administrative person who is responsible for coding to learn how codes are selected for your services.
Last but not least...the Health Insurance Portability and Accountability Act, or HIPAA. HIPAA protects the privacy and security of health information. It also establishes the recognized code sets for reporting diagnoses and procedures. It has an impact on how you document and bill. If you become employed in a health care facility you will receive training through your employer. More information is available on the ASHA reimbursement website.
For general reimbursement information for speech-language pathologists you should visit the ASHA billing and reimbursement site.
At this time please proceed to Module Six, which covers coding, documentation, and additional reimbursement reporting requirements for audiology or Module Seven, which covers advocating for our professions.