See also: FAQs: Stuttering Reimbursement
If you choose to assist in the appeal:
ASHA's "Health Plan Coding and Claims Guide" provides resources on coding, billing, appeals, denials, and other helpful information. This guide is available through the ASHA online store or through ASHA's Product Sales at 1-888-498-6699. Ask for Item #0112486.
A list of CPT codes with short descriptors and associated fees for speech-language pathology and audiology can be found in the Medicare Fee Schedule or the Superbill for Speech-Language Pathology Practice [DOC]. Go to the American Medical Association (AMA) website to order the official CPT Manual.
A superbill is a time efficient form to document services, fees, codes, and other information required by health plans. Models are available for download by selecting Superbill for Audiology Practice [DOC] or Superbill for Speech-Language Pathology Practice [DOC].
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 black and white copies through the CMS website or obtain copies from your local Medicare carrier, local printing companies, or the Government Printing Office (212-512-1800).
There is no uniform standard for private payers, so we look to Medicare's guidance.
Federal Medicaid regulations define CFs as qualified speech-language pathologists and do not mention licensure. However, a state Medicaid program can supercede Federal regulations when the state requirement is more stringent. Thus, Medicaid programs could require licensed practitioners and disallow non-licensed CFs.
For private health plans, check with the payer in question to determine their provider qualifications. Often, private health plans develop policies that are consistent with those of Medicare.
Under Medicare, the Fiscal Intermediary (FI) or carrier determines if the SLP assistant's services are covered and specifies the required level of supervision. An FI, Carrier, Medicaid, or private health plan may require that the assistant is registered or licensed by the state.
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 they 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.
You may refer to the Medicare Fee Schedule for a general idea of what Medicare reimburses for specific procedures. It is important for you to know that Medicare rates reflect a budgetary constraint and may not reflect current market rates. You can also purchase historic fee data from medical coding publishers.
Discussing fees with other local practices may be construed as price-fixing. Setting prices in collusion with colleagues is illegal.
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 or audiologist 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.