Medicaid Reimbursement For Speech Therapy

Cpt Code : Auditory Processing Disorders

This code includes treatment of speech, language, voice, communication, and/or auditory processing disorders. The individual patient undergoes developmental programs under the direction of a physician. These include:

• Lip-reading instruction
• Hearing rehabilitation

The patient in these cases is typically a child who has problems processing information they hear. This is often due to a lack of integration between the ears and the brain. In the case of an auditory processing disorder, even though the patients hearing abilities may be normal, they may have difficulty understanding aural information.

Medicares Past And Parts

President Lyndon B. Johnson when he signed the Social Security Amendments of 1965. Medicare first provided health care coverage to Americans enrolled in cash assistance programs. In 1972, the program expanded to cover people ages 65 and older and those who have a disability or end-stage renal disease.

Today, Medicare covers those over 65 years old, and people of all ages who have mental and physical disabilities, pregnant women, families with low income, and those who need long-term care. According to Medicares Enrollment Dashboard, about 64 million Americans received health coverage through the program in 2021.

Medicare initially provided medical and hospital coverage. Today, Medicare insurance also covers prescription drugs, home health, and hospice, including treatments that fall under the rehab therapy umbrella. The Centers for Medicare and Medicaid Services manage the components of Medicare: Part A , Part B , Part C , Part D , and Medigap, an optional policy that helps with out-of-pocket Medicare costs.

Cmss Annual Proposed And Final Rules

Each year, CMS releases possible changes in a proposed rule for the upcoming year, followed by a comment period, and ending with a final ruling after the public comment period has ended. Anyone is welcome to leave a comment on the proposed ruling, and CMS will publish their final rule on their website, prior to the next calendar year when it takes effect. The agency published the final rule for 2022 on November 2, and you can read the final rule in its entirety on the Federal Register.

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Cpt Code : Evaluation Of Speech Fluency

Finally, lets go over CPT code 92521. This is one of the most important medical codes for speech therapists. It refers to the evaluation of speech fluency, specifically speech fluency disorders such as stuttering, cluttering, etc.

Be aware that anterior rhinoscopy, tuning fork testing, otoscopy, removal of non-impacted cerumen, and other diagnostic/treatment services not generally included in E/M service are bundled into CPT code 92521.

To choose this CPT code, the provider evaluates the patients fluency level with a quantitative and qualitative assessments. They may take a measurement of speaking rate such as SPM .

The provider then documents the severity, frequency, secondary characteristics, self-awareness/self-correction/perception, and types of disfluencies during the encounter with the patient.

Once again, medical documentation is key in selecting the correct CPT code for speech therapy medical billing.

Is the provider evaluating speech fluency or speech sound procedure? The general rule is that, if a service is not documented, it didnt actually occur.

Hence, the providers must document everything properly and accurately in order to avoid incorrect billing and be paid on time.

Are you concerned about receiving and validating the necessary information on time? Check out these custom online fillable forms from Practice Tech Solutions!

Medicare Audits And Other Concerns

As a provider, you are expected by CMS to know and follow the complicated Medicare rules for rehabilitative therapy. In addition to a claim being denied or delayed, CMS can also audit your practice if certain red flags are raised due to billing practices or documentation issues.

Preparing for a Medicare audit requires you to invest a great deal of time and money, and willingly participating in an audit doesnt guarantee that youll avoid fines and penalties from CMS, either.

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Abbvie Announces Ontario To Begin Reimbursement For Maviret Hcv Therapy

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AbbVie announced an agreement with the pan-Canadian Pharmaceutical Alliance in which Ontario will be first province to reimburse the hepatitis C direct-acting antiviral Maviret on its public formulary as of February 28, 2019, according to a press release.

After more than 20 years of treating hepatitis C, I am hopeful that soon we will successfully eliminate this virus. But in order to reach this goal in Canada and across the world, we need to work together to test, diagnose and bring these high curative treatments to every individual, regardless of their genotype, fibrosis stage and background,Magdy Elkhashab, MD, director of the Toronto Liver Center. As a hepatologist, MAVIRET offers me the opportunity to put my patients on an effective, short duration therapy that has a proven track record.

Under the agreement, Maviret will be covered for both treatment-naive and treatment-experienced adult patients with chronic hepatitis C infection regardless of fibrosis stage.

Several recent studies have confirmed that Maviret safely and effectively treats HCV genotypes 1 through 6 within an 8-week course for most patients.

Reference: www.abbvie.ca

Providers: How To Accept And Treat Medicare Patients

To treat Medicare beneficiaries , you must become certified or credentialed through CMS as a licensed OT, PT, or SLP rehab provider. Start by obtaining an NPI on the National Plan & Provider Enumeration System if you dont have one already. Then, complete the online Medicare Enrollment Application.

After applying, a Medicare Administrative Contractor will reach out to complete the process and may request additional information. CMS will assign a coordinator who has experience in the regulations that apply in your state. Once you receive your Medicare billing credentials, you must let CMS know 30 days in advance if you move to a new practice location, change owners, or experience legal sanctions.

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Rules For Using Assistants Techs Or Students

Assistants, techs, and therapy students can all make a measurable difference in freeing up a providers time or lightening their workload. But, due to Medicares strict licensing requirements for services, clinic technicians and therapy students are not able to be reimbursed for provided services.

Therapy assistants, however, are eligible for partial reimbursement for provided services when they are supervised by a licensed provider. When billing, CMS requires using the CQ or CO modifier to indicate services provided by an occupational therapy assistant or a physical therapy assistant .

Since 2020, clinics have been required to report the use of an assistant on claims, but as of January 1, 2022, Medicare will reduce reimbursement by 15% for services provided in whole or in part by an OTA or PTA. Depending on how often you use assistants at your clinic, the 15% cut in reimbursements can become significant. The billing rules around the CO and CQ modifier are complex, but weve tackled the topic in our Assistant Modifier Guide.

Physician Referrals And Medicare Plan Of Care

Medicare requires a plan of care that is written and initiated by the therapist and certified by a physician or non-physician practitioner. Oftentimes, Medicare patients are referred by a primary physician to a rehabilitative therapist, but physician referrals are not always a requirement for seeking care.

In general, Medicare outpatient rehabilitation providers agree to provide and document the following elements of patient care in their Plan of Care:

• Diagnosis, dysfunction, or impairment, including both objective and subjective notes from the provider and patient.
• Assessment of the patients desired outcomes and potential for rehabilitation.
• A comprehensive plan of care that includes:
• The time frame of care
• Interventions and services provided
• Long-term goals for the patient
• Frequency and duration of treatment sessions

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Billing And Reimbursement Frequently Asked Questions

ISHA’s Billing and Reimbursement Committee has provided answers to some of the frequently asked questions regarding billing and reimbursement this was updated on August 29, 2022.

Question: Can potential clients with Medicaid and/or Medicare pay for services out of pocket?Answer: This question comes up frequently. In order to address it in the best way we need to break it down into parts:

A provider contracted with Medicaid: Providers willing to accept Medicaid cannot charge the recipient for Medicaid services and agree to accept Medicaid reimbursement as payment in full. Some KidCare programs, however, require recipients to pay various co-payments, the amount of which depends on the program under which they are covered. A provider may not refuse treatment to a person who has not paid their co-payment.

Providers who have agreed to accept Medicaid payment for service may not seek payment from the recipient if Medicaid payment is not made due to the providers failure to follow the procedures required in order for the provider to obtain Medicaid reimbursement. A provider has accepted Medicaid payment if:

Physicians and suppliers are not required to file claims on behalf of Medicare beneficiaries for:

Best practice tips:

Mips Mvps And The Future Of Medicare Reimbursements

CMS has gradually been taking steps to transition from service-based to value-based reimbursement models. Currently, CMS offers payment bonuses or penalties to eligible Part B rehabilitative therapy clinics through the Merit-Based Incentive Payment System . Over a gradual rollout of the program, MIPS is designed to reward clinics based on their performance within four categories: quality, advancing care information, improvement activities, and cost or resource use.

Whether you receive a negative or positive adjustment depends on objectives called MVPs . You can receive higher reimbursement by successfully completing MVP activities and measures. If youre curious to learn more about participating in MIPS or MVPs, check out our MIPS 101 blog post, or visit our partner Keet Health, a QCDR-certified application for rehab therapists.

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Speech Therapy Medical Billing & Coding Guide For 2022

Here we present a medical billing and coding 101-guide for speech therapists and speech-language pathologists.

We will look at the most commonly used CPT codes, the differences between them, and the designation of time, modifiers, and proper documentation.

Choosing the correct CPT codes will ensure that your speech therapy practice always receives proper reimbursement for services provided. It will help you stay fully compliant with CMS guidelines and avoid costly, time-consuming rejections.

We hope that this guide will provide the expertise and experience you will need to prevent claim denials and maximize cash flow at your practice.

Dont leave money on the table. The more clean claims your practice submits on the first try, the more time youll have to practice speech therapy and provide care to patients who need it most.

This guide is based on ICD-10-CM, which officially took effect in October of 2021 and will apply for CY 2022.

The Therapy Threshold Or Kx Modifier Threshold

While Medicare Part B does cover a range of rehab therapy services, patients are subject to a therapy threshold. Providers can provide services that exceed the threshold if they certify the medical necessity of that care using the KX modifier when billing for reimbursement.

CMS adjusts the threshold annually, and the KX modifier threshold will increase from $2,110 in 2021 to $2,150 as of January 1, 2022. Without the KX modifier in place, CMS will likely deny any rehab services that surpass the threshold. Luckily, some EMR systems, including the Insight Platform, can automatically track the threshold for each Medicare patient and can notify therapists and billers when a patient is near the max or may require the modifier.

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A Providers Golden Rule: Medical Necessity And Defensible Documentation

Besides credentialing, another aspect of Medicare compliance that providers will need to maintain is accurate chart notes that defensibly document their medically necessary care for Medicare patients. Medical necessity is required to receive reimbursement for rehab therapy services from Medicare. Your claim must clearly show that the treatments you provided meet the currently accepted medical standards for the patients condition.

To fulfill the medical necessity standard, always strive to submit defensible documentation. In other words, your documentation should be able to legally prove medical necessity in the case of a Medicare audit. Your notes should illustrate the patients diagnosis, condition, and limitations and explain how the provided therapies address these issues. Detail the treatments you provided during the session and for how long. Include the care plan, measurable goals, and progress toward those goals, as well as subjective and objective observations .

Billers Beware: Ncci Edit Pairs And Mppr Impacts

Two common hurdles for Medicare billing are the National Correct Coding Initiative code edits and the multiple procedure payment reduction . Both of these compliance topics can negatively impact practice revenue if not followed correctly.

NCCI code edits consist of a list of CPT codes that should not be billed together, otherwise known as procedure-to-procedure edits. If code pairs appear on a claim, they can trigger an immediate denial for reimbursement. NCCI also blocks medically unlikely edits , which occur when your claim exceeds the maximum service units for a single person on the same day. NCCI edits update annually and have a history of causing claim issues as clinics adapt to new PTP edits. We talk about that history and other compliance concerns for clinics on our NCCI Edits guide.

MPPR decreases the practice expense portion of a reimbursement by 50% when multiple units of specific services considered always therapy are billed together on a claim. MPPR reduces practice payment received for every service provided to a patient after the first in a single day, even when your patient saw providers in multiple rehab disciplines. There are ways clinics can mitigate the impact of MPPR, which we discuss further in our MPPR guide.

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Cpt Code : Speech Sound Production And Expressive Language

Another example of how a CPT code must provide specific information in the medical record in order to choose the code for billing purposes is CTP code 92523.

This code refers to the evaluation of speech sound production. This may include articulation, phonological process, apraxia, or dysarthria. It also includes the evaluation of language comprehension and expression, namely receptive and expressive language.

Documentation must include:

• The ability to execute motor movements needed for speech
• A determination of the patients ability to create and communicate expressive thought
• An evaluation of the patients ability to produce speech sounds

The physician takes a patient history, including speech and language development, hearing loss, and physical and mental development, and performs a physical examination.

Speech and language evaluations are conducted. Assessment of any deficits is noted and a treatment plan for the patient is developed. This plan could involve speech therapy, hearing aids, etc.

Types Of Audits And Other Resources

CMS conducts several different types of audits depending on the billing issues at hand:

• MAC audit: An audit from a Medicare Administrative Contractor addresses improper reimbursements. With a MAC audit, the contractor can medically review all practice claims, request additional documentation, and gather outside data to detect billing problems.
• RAC audit: An audit from a Recovery Audit Contractor focuses on finding and fixing incorrect payments. The RAC can request information and documentation from your practice to complete the audit.
• CERT audit: A random audit from a Comprehensive Error Rate Testing contractor analyzes the statistical likelihood of payment errors. As with other types of audits, you will likely receive a documentation request if you have a claim selected for CERT.
• ZPIC audit: Zone Program Integrity and Program Safeguard audits take effect when Medicare has reason to suspect purposeful fraud. Zone Program Integrity Contractors conduct the audits.

Preparing for an expected audit can reduce your chances of accruing costly penalties. Consult these resources if you receive an audit notice from CMS:

• Medicare Fee for Service Recovery Audit Program | CMS

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Medicare Is Complicated But Your Clinic System Doesnt Have To Be

At Clinicient, our Insight Platform is designed to simplify the complex. With a plethora of automations for billing, documentation, and compliance, clinics can submit more claims, faster, and stay on top of Medicare updates before they happen. The Insight Platform is equipped with:

• An automated unit calculator for the 8-minute rule and a therapy threshold tracker, with customizable smart alerts.
• Automatic updates when new rules are released, plus customizable billing rules for commercial, private, and government payers.
• An analytics and reporting suite with simple dashboards to track revenue, first-pass payment rates, and denials, so you can stay on top of potential compliance concerns.
• Customizable documentation and letter templates, plus a whole lot more.

Whether you need a better EMR, a faster billing engine, or the complete package from referral to reporting, the Insight Platform is designed to meet the needs of outpatient rehab therapy clinics of all sizes.

Common Cpt Code Modifiers Used In Speech Therapy Medical Billing

Modifiers are used to indicate that a service or procedure performed has been altered by some specific circumstance but not changed in its definition or code.

The following modifiers may be used when reporting speech-language therapy:

• Modifier -GN: when Medicare Part B services are provided under plans of care for speech-language pathology.
• Modifier -KX: when the clinician attests that services at and above the therapy caps are medically necessary and reasonable, and justification is documented in the patients medical record.
• Modifier -22: when the physician believes the work required to provide a service is substantially is greater than typically required. Documentation must support this substantial additional work and the reason for it.
• Modifier -52: when a service or procedure is partially reduced or eliminated at the physicians discretion.
• Modifier -59: to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.

There are also restrictions on certain CPT code pairs billed on the same day. For these, the medical billers should refer to the National Correct Coding Initiative edits.

The providers must also note that cognitive therapy by speech-language pathologists is covered in most Medicare Part B and commercial insurance.

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