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2014 REIMBURSEMENT UPDATEIMPACT ON EDUCATION AND CLINICAL PRACTICE FOR COMMUNICATION SCIENCES AND DISORDERS- PART ONE

Dee Adams Nikjeh, Ph.D., CCC-SLP

Annual CAPCSD ConferenceApril 10, 2014

DISCLOSURES Dee Nikjeh has financial relationships to disclose

Mileage and one-night’s stay are covered for this presentation

She is a paid consultant for the U.S. Department of Justice to investigate Medicare fraud

Dee Nikjeh has nonfinancial relationships to disclose She is Co-Chair of ASHA’s Health Care Economics

Committee She is advisor to the American Medical Association’s

Relative Value Update Committee/Health Care Professionals Advisory Committee

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AGENDA

Two Health Care Coding Systems Which is what? (CPT and ICD) What are the principles of coding?

2014 Medicare Physician Fee Schedule How do procedures get a value and a fee? What factors in 2014 will affect fee payment?

Four New SLP Evaluation Procedure codes How do we use modifiers and edits appropriately for these new

procedures? How are these procedures used in place of CPT 92506?

Professional Work What defines skilled care? What is S.M.A.R.T. documentation? 3

TWO HEALTH CARE CODING SYSTEMS

Understanding the coding systems is essential in any discussion of reimbursement and coding.

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TWO HEALTH CARE CODING SYSTEMS

Procedural Codes – Describe what we DO with the client/patient Current Procedural Terminology, a.k.a. CPT codes

Diagnostic Codes – Describe the REASON we are evaluating or treating the client/patient International Classification of Diseases, 9th Revision,

Clinical Modification, a.k.a. ICD-9 codes

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Understanding the Codes

INTERNATIONAL CLASSIFICATION OF DISEASES, NINTH REVISION, CLINICAL MODIFICATION (ICD-9-CM)

ICD-10 POSTPONED…AGAIN…6

INTERNATIONAL CLASSIFICATION OF DISEASES, 9TH REVISION, CLINICAL MODIFICATION (ICD-9-CM)

Numeric classification system of diseases and disorders Chapters are based primarily on body systems (e.g.,

circulatory, respiratory, nervous) Code or codes to describe the problem or reason for our

procedure Issued by the U.S. Department of Health and Human

Services Approximately 15,000 codes

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RESOURCES

ICD-9-CM Codes for SLPs:www.asha.org/practice/reimbursement/coding/icd9SLP.htm

Guidelines for Coding & Reporting ICD-9-CM:www.cdc.gov/nchs/data/icd9/icdguide.pdf

ICD Home Page: www.cdc.gov/nchs/icd9.htm Questions: e-mail reimbursement@asha.org

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ICD-10-CMBEGINS OCTOBER 1, 2015

ICD-10 includes approx 160,000 ICD-10-CM diagnosis codes for all settings (> 68,000) ICD-10-PCS procedure codes for hospital inpatients

Greater specificity3-7 alphanumeric characters instead of 3-5 digits (ICD-9-CM)

Code descriptors have more detail, less room for error Combination codes represent disease & systems Clearer instructions than ICD-9-CM Accommodate current, complex, and future health care

needs9

INTERNATIONAL CLASSIFICATION OF DISEASES-CLINICAL MODIFICATION (ICD-CM)

Purpose Standardize disease and procedure classification

throughout the US Gather data about basic health statistics and trends Code and classify mortality data from death certificates

Clinical Modification – Developed by Center for Disease Control and Prevention (CDC)

Owned by the World Health Organization (WHO)

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PRINCIPLES OF ICD CODING

Code to the highest degree of medical certainty or specificity

Avoid Not Otherwise Specified (NOS) and Not Elsewhere Classified (NEC)Codes

Primary diagnosis is condition (disease, symptom, injury) chiefly responsible for visit or reason for encounter

Secondary diagnoses is co-existing conditions or symptoms, or condition found after study

If results of diagnostic testing are NORMAL, code signs or symptoms to report the reason for test/procedure and explain normal result in report

The procedure (CPT code) should be appropriate for the condition or reason (ICD code) for encounter 11

ICD-9 TO ICD-10 ASHA MAPPING TOOLS

Online Mapping Tools for ICD-9 to ICD-10 codes Enter the ICD-9 code and a list of the corresponding ICD-

10 codes is generated Mapping Spreadsheet to view related mappings in one list

A list of SLP and AUD ICD-10 codes, much like the current ICD-9 list on the ASHA website

Products are free and tailored for speech-language pathology and audiology

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ASHA ICD-9 TO ICD-10 MAPPING TOOL

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3 1 5 . 93

ASHA ICD-10 MAPPING TOOL

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EXAMPLES OF ICD-10-CM FOR SLP

F80.1 Expressive language disorder

F80.81 Childhood onset fluency disorder

F80.4  Speech and language development delay due to hearing loss

I69.020  Aphasia following nontraumatic subarachnoid hemorrhage 

I69.120  Aphasia following nontraumatic intracerebral hemorrhage 

I69.320  Aphasia following cerebral infarction

R13.11 Dysphagia, oral phase

R41.841  Cognitive communication deficit 

R48.8 Other symbolic dysfunctions

R49.21 Hypernasality15

ICD-10: QUESTIONS FOR CMS  Will Oct. 1, 2015, become the new deadline? Will the agency allow organizations that are ready to

implement ICD-10 to do so voluntarily? Will agency scrap ICD-10 altogether and instead, wait

for ICD-11 which is due to e released in 2017?

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RESOURCESICD-10-CM

ASHA Website for ICD-10 www.asha.org/Practice/reimbursement/coding/ICD-10/

ICD-9 to ICD-10 ASHA Mapping Toolwww.asha.org/icdmapping.aspx

National Center for Health Statistics Website: www.cdc.gov/nchs/icd/icd10cm.htm

Centers for Medicare & Medicaid Services Website: www.cms.gov/ICD10/

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2014 CPT

“… a set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other health care providers.”

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CURRENT PROCEDURAL TERMINOLOGY AKA CPT CODES Every medical, surgical, and diagnostic procedure

assigned a 5-digit code CPT codes are used to

Simplify the reporting of services Ensure uniformity of communication

Approximately 8,000 codes Developed, maintained, and copyrighted by the

American Medical Association (AMA) Updated annually

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RELATIVE VALUE UNIT (RVU)

Every CPT procedure or service has a resource-based relative value

Payments for services are determined by the resource costs needed to provide them

3 components make up a relative value Professional workPractice expenseProfessional liability insurance

All procedures are ranked on this same scale Standardized physician payment schedule

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MEDICARE IMPROVEMENTS FOR PATIENTS AND PROVIDERS ACT OF 2008 (MIPPA)

MIPPA – Effective July 1, 2009 Granted SLPs independent billing to Medicare Changed our status with CMS to a Medicare Provider Recognized SLPs as professionals rather than technical

assistants Allowed for the “relative value” of SLP CPT (procedure)

codes to be re-valued to include a professional work component

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THREE COMPONENTS OF RELATIVE VALUE UNIT

*Professional Work* Time it takes to perform the service Technical skill and physical effort Required mental effort and judgment Stress due to the potential risk to the patient

Practice Expense Time of support personnel** Supplies Equipment Overhead

Professional Liability/Insurance Costs

2014MEDICARE PHYSICIAN FEE SCHEDULE

Extended through March 31, 201523

MEDICARE PHYSICIAN FEE SCHEDULE RVU X Monetary Conversion Factor = Medicare Payment per

Procedure

Payment adjusted for geographic location

Conversion Factor for 2013 = $34.0376

Conversion Factor for 2014 = $35.8228

• 0.5% increase

• Pathway for SGR Reform Act of 2013 – Law 12-26-13

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www.asha.org/practice/reimbursement/medicare/feeschedule/

FACTORS AFFECTING PAYMENT SCHEDULE

Conversion Factor Sustainable Growth Rate (SGR) Therapy Cap and Medical Manual Review Sequestration Multiple Payment Procedure Reduction Geographic location

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CONVERSION FACTOR - WHAT’S THAT ?…OR WHAT WAS THAT?

CF based on the Medicare Sustainable Growth Rate (SGR) SGR enacted by the Balanced Budget Act of 1997 Method used by CMS to control Medicare spending by

physician services CF recommended to Congress by CMS

CF changes payments for physician services for the next year in order to match the targeted SGR

If expenditures for previous year exceeded targeted expenditures, then conversion factor decreased payments for the next year and vice versa

Despite CMS recommendations for major cuts to the CF, Congress has not changed CF since 2011 

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SUSTAINABLE GROWTH RATE REPEALED ? REFORMED? REPLACED?

March 31, 2014 - 12-month patch Extends current 0.5% update through the end of 2013 Freezes payment rates until March 31, 2015 Extends Therapy Cap Extends Post-payment Manual Medical Review

Senate and House agree on Repeal but not on the details Congress has passed 17 such patches over past 11 years

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MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) – LOOKING TO THE FUTURE

Incentive payment program that will focus the fee-for-service system on providing value and quality on patient performanceQuality measuresResource useClinical practice improvement activitiesElectronic Health Record meaningful use

May professionals with the opportunity to receive additional payment adjustments through use of this merit-based system

Stay tuned…more to come29

MANUAL MEDICAL REVIEW OF THERAPY SERVICESCONTINUES AT LEAST UNTIL APRIL 1, 2015

Therapy cap of $1,920 continues for combined PT and SLP

Continue to use the KX modifier at $1,920 limit

Exceptions Process – For Medicare Part B therapy services that exceed the $3,700 threshold the post-payment (all states) manual medical review continues

Resources Ingrida Lusis, ASHA's director of federal and political

advocacy, at ilusis@asha.org

Questions related to the therapy cap exceptions process, should be directed to reimbursement@asha.org.

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MULTIPLE PROCEDURE PAYMENT REDUCTION (MPPR)

Reduces practice expense (PE) payment for second and subsequent procedures provided on the same day to the same patient for Medicare Part B services

Expanded to therapy services in 2011 50% decrease in PE fees for Part B services in all settings

New SLP evaluation procedure codes are included in MPPR

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SEQUESTRATION

2% reduction on the 80% Medicare payment continues

No end in sight for this…

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CPT 92506 EVALUATION OF SPEECH, LANGUAGE, VOICE, FLUENCY, COMMUNICATION AND/OR AUDITORY PROCESSING

“Please describe the typical patient and explain to us exactly what you do for procedure 92506.”

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FOUR NEW SLP EVALUATION PROCEDURE CODES REPLACE CPT 92506 JANUARY 1, 2014

92521 - Evaluation of speech fluency (e.g., stuttering, cluttering)

92522 - Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria)

92523 - Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) with evaluation of language comprehension and expression (e.g., receptive and expressive language)

92524 - Behavioral and qualitative analysis of voice and resonance

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CPT 92521 - EVALUATION OF SPEECH FLUENCY (E.G., STUTTERING, CLUTTERING)

Vignette for CPT 92521

A 7-year-old male presents with stuttering that includes behavioral (e.g., repetitions, prolongations, and blocks) and affective (e.g., avoidance and/or reduction of communication interaction) responses that negatively impact his communication function.

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CPT 92522 - EVALUATION OF SPEECH SOUND PRODUCTION (E.G., ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA)

Vignette for CPT 92522

A 6-year-old male presents with age-appropriate language comprehension and expression; yet, his speech sound production is unintelligible and negatively impacts his abilities to successfully communicate with others.

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CPT 92523 - EVALUATION OF SPEECH SOUND PRODUCTION (E.G., ARTICULATION, PHONOLOGICAL PROCESS, APRAXIA, DYSARTHRIA) WITH EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION (E.G., RECEPTIVE AND EXPRESSIVE LANGUAGE)

Vignette for CPT 92523

A 5-year-old male presents with significant deficits of receptive, expressive, and social language and highly unintelligible speech sound production that limit his abilities to understand and communicate effectively in daily social and educational activities with family and peers.

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CPT 92524 - BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE

Vignette for CPT 92524

A 38 year-old female diagnosed with bilateral vocal cord nodules was referred for an evaluation of functional voice use and resonance to facilitate the design of a voice therapy/behavioral treatment plan. The patient complains of progressive hoarseness, inadequate projection, altered resonance, vocal fatigue, and tightness and pain in her throat which compromises her ability to communicate effectively.

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WHY IS THERE NOT A LANGUAGE-ONLY EVALUATION PROCEDURE CODE? Language-only evaluation for children is rare in the absence of

speech sound production Survey of practices/clinics confirmed that this occurs less than

20% of the time However, speech-sound production commonly evaluated in absence

of language testing If two or more procedures are billed together greater than 51% of

the time, CMS considers them to overlap and will bundle the procedures and decrease the reimbursement

If evaluating only language, may code 92523 with the

-52 modifier* indicating reduced service Keep in mind SLPs have evaluation procedure codes for standardized

cognitive assessment, developmental assessment, and aphasia 39

BILLING CODES TOGETHER? Sometimes it is appropriate for more than one disorder to be

evaluated on the same day or for more than one procedure to be billed on the same day

Documentation should clearly reflect a complete and distinct evaluation for each disorder

Evaluation codes should not be billed for brief assessments that could be considered screenings

Time for identification of other disorders is already built into the value of each code

Inappropriate use of multiple evaluations on same day will result in restrictions through the National Correct Coding Initiative (CCI) edits

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EDITS AND MODIFIERS

Coding Clarification

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CODING CLARIFICATIONS - EDITS

ο Two types of similar edit systems depending on setting ο National Correct Coding Initiative (CCI) – any Part

B services not rendered in a hospitalο Outpatient Code Editor (OCE) – outpatient hospital

servicesο Automated edit systems used by CMS to control

specific CPT code pairs that can be reported on the same day for the same patient

ο CCI is updated quarterly and OCE follows one quarter later

ο Since late 2010, CCI also applies to Medicaid per federal law

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CODING CLARIFICATIONS-EDITS

Some procedures considered to be “mutually exclusive” and may not be billed together for the same patient on the same day

Examples for SLP 92607 (Speech-generating device evaluation) & 92597

(Voice prosthetic evaluation) 92507 (Speech, lang tx) & 97532 (Cog tx) 92522 (Speech eval) & 92523 (Speech & Lang eval)

SLP CCI Edits can be found at www.asha.org/practice/reimbursement/coding/CCI_edits_SLP.htm

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MEDICALLY UNLIKELY EDITS (MUES) Subset of CCI edits also for Medicare Part B and

Medicaid claims Specifies maximum number of times that a CPT code

can be reported on same day for same patient Separate MUEs for office and hospital outpatient

settings, but SLP MUEs are similar for both 92507 1 speech tx 92526 1 dysphagia tx 96105 3 aphasia assessment per hour 96125 2 cognitive performance testing per hour

For a complete list of SLP-related MUEs, see: www.asha.org/Practice/reimbursement/coding/Medically-Unlikely-Edits-SLP/

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CODING CLARIFICATIONSPECIAL CIRCUMSTANCES- MODIFIERS

-59 Indicates Distinct Procedural Service Only modifier used with NCCI edits For two procedures not ordinarily performed on the same day

by the same practitioner, but which, under certain circumstances, may be appropriate to perform and therefore code on the same day (e.g., different site or organ system)

Who provides the service GN: Speech-language pathologist GO: Occupational therapist GP: Physical therapist

Severity Level Modifiers with G-codes for functional claims reporting

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EXAMPLES OF MODIFIERS SOMETIMES USED BY SLPS

“-52” indicates an abbreviated procedure

“-59” indicates that two procedures are distinct and separate CPT 92611 (MBS) & 92610 (Clinical Swallow Eval)

CPT 92526 (Dysphagia tx) & 97532 (Cog tx)

CPT 92508 (Group tx) & 92507 (Indiv tx)

CPT 96105 (Aphasia assessment) & 96125 (Cognitive Performance testing)

“-22” indicates a much longer than usual procedure

“-76” indicates a repeat procedure by the same provider on the same date of service

ASHA CCI EDIT PAGE FOR SLP CODES

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www.asha.org/practice/reimbursement/coding/CCI_edits_SLP.htm

ASHA RESOURCES

ᴏ Manual Medical Reviewᴏ www.asha.org/Practice/reimbursement/ExceptionProcess/

ᴏ Medicare Physician Fee Scheduleᴏ www.asha.org/practice/reimbursement/medicare/feeschedule/

ᴏ National Correct Coding Initiative (CCI Edits)ᴏ www.asha.org/practice/reimbursement/coding/CCI_edits_SLP.h

tm

ᴏ Medically Unlikely Edits (MUEs)ᴏ www.asha.org/Practice/reimbursement/coding/Medically-Unlik

ely-Edits-SLP/

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NEW SLP EVALUATION CODESQUESTIONS AND ANSWERS

CPT 92521CPT 92522CPT 92523CPT 92524

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SCENARIO 1: SLP CPT QUESTION

May I bill CPT 92522 and 92523 together on the same day?

CPT 92522 - Evaluation of Speech-sound production (e.g., articulation, phonological process, apraxia, dysarthria)

CPT 92523 - Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) with evaluation of language comprehension and expression (e.g., receptive and expressive language)

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SCENARIO 1: SLP CPT ANSWER

No, do NOT Code these two together, only one or the other CPT 92523 INCLUDES the evaluation of speech sound

production

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SCENARIO 2: SLP CPT QUESTION

When I evaluate a child who has a cleft palate and speech and language problems, what procedures may I code?

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SCENARIO 2: SLP CPT ANSWER

CPT 92523 Speech-sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language)

CPT 92524 Behavioral and qualitative analysis of voice and resonance

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SCENARIO 3: SLP CPT QUESTION

I evaluate an adult with a voice disorder, using the new procedure code CPT 92524 (Qualitative and behavioral analysis of voice and resonance). Patient has no resonance disorder.

Do I code CPT 92524 with -52 modifier to indicate a shortened evaluation?

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SCENARIO 3: SLP CPT ANSWER

-52 modifier is not required if only voice or only resonance is evaluated

Descriptor of CPT 92524 is written so that voice and/or resonance may be evaluated

Recommend a statement of observation that one or the other is not impaired

Code developed so that those who work with cleft palate have appropriate choices of procedure codes 

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SCENARIO 4: SLP CPT QUESTION

I am evaluating a patient who has Parkinson’s disease. He has dysarthria and a voice impairment. May I do more than one evaluation procedures and which procedures codes may I use?

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SCENARIO 4: SLP CPT ANSWER

YES CPT 92522 Speech-sound production(e.g.,

articulation, phonological process, apraxia, dysarthria)

CPT 92524 Qualitative and behavioral analysis of voice and resonance

Document completely including your recommendations for plan of care based on your two evaluations

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SCENARIO 5: SLP CPT QUESTION I am evaluating a patient who is referred because

of cognitive impairment. I used to code CPT 92506. What should I do now?

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SCENARIO 5: SLP CPT ANSWER

You may use CPT 96125 (Standardized cognitive performance testing, per hour) for evaluation of cognitive skills and abilities

CPT 96125 is a per hour code which requires at least 31 mins for one hour or 91 to 151 mins for two hours of billing. This includes administration and documentation. Standardized and nonstandardized subtests may be included in the battery of measurement tools.

Cognitive assessment using informal tools and lasting less than the 31 mins may be considered a screening and payment may be denied.

For language only, possible to code 92523 with -52 modifier. Caution: Value for shortened procedure has not been established.

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SCENARIO 6: SLP CPT QUESTION

What if I provide both a cognitive assessment AND a speech sound production with language evaluation? How do I code this?

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SCENARIO 6: SLP CPT ANSWER Few circumstances (e.g., child with language-learning disorder)

may warrant both complete cognitive evaluation (CPT 96125) and evaluation of speech-sound production with receptive and expressive language (CPT 92523).

If you complete both a full cognitive evaluation and a comprehensive speech & language evaluation, you may bill CPT 96125 AND 92523 with -59 modifier on 96125

Documentation must show separate and distinct procedures Combine with CAUTION; Cognitive treatment (97532) and

speech and language treatment (92507) may NOT be billed together on the same day to same patient b/c of overlap

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SCENARIO 7: SLP CPT QUESTION

What if it takes two visits to complete CPT 92523 (speech sound production with language evaluation) and then 45 minutes to interpret and complete documentation? Can I bill CPT 92523 for 3 visits?

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SCENARIO 7: SLP CPT ANSWER

No, CPT 92523 is not a timed code and may only be billed once.

The value of the code includes 120 minutes of intra-service time.

Recommend to complete as much of the evaluation as possible on the initial visit and if necessary, complete the additional tests and measures during the subsequent treatment sessions.

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SCENARIO 8: SLP CPT QUESTION

I see a child for a speech fluency evaluation and also perform an oral peripheral examination.

Can I bill CPT92521 (Evaluation of speech fluency) and 92522 (Evaluation of speech sound production)?

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SCENARIO 8: SLP CPT ANSWER

No. An oral peripheral examination is an integral part of

every speech, language, fluency, and voice evaluation and the time spent on the examination of is already built into each evaluation code.

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SCENARIO 9: SLP CPT QUESTION

What do I code for reevaluations?

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SCENARIO 9: SLP CPT ANSWER

Because evaluations are provided for children and adults who have communication impairments and much of our testing is standardized to establish basal and ceilings, age norms, percentiles, etc., the reevaluation is just as detailed as the initial evaluation.

For that reason, SLPs do not have reduced reimbursement for reevaluations.

Document your evaluation findings and compare to previous evaluation 67

RE-EVALUATIONWHEN IS IT APPROPRIATE? A formal re-evaluation is covered if documentation supports need for further tests

and measurements after initial evaluation Indications for a re-evaluation

New clinical findings, Significant change in the patient's condition, Failure to respond to therapeutic interventions outlined in plan of care.

Re-evaluation is focused on Evaluation of progress toward current goals Making a professional judgment about continued care Modifying goals and/or treatment Terminating services

Re-evaluation may be appropriate Prior to discharge to determine whether goals have been met For use by physician or treatment setting where treatment will be continued

Continuous assessment of patient's progress is a component of ongoing therapy services and not payable as a re-evaluation

220.3 - Documentation Requirements for Therapy Services

(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)

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SCENARIO 10: SLP QUESTION

What do I code if I do a pediatric language-only evaluation?

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SCENARIO 10: SLP ANSWER In the atypical evaluation when only a child’s language is

evaluated, SLPs may bill 92523 with the -52 modifier, which is used to indicate a shortened procedure compared to the full description of the service.

CAUTION: There is no established value for a shortened procedure

CPT 96125 (Standardized cognitive performance testing, per hour) or CPT 96111 (Developmental testing -- includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments with interpretation and report) may be appropriate options

Recommend including evaluation of speech-sound production

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SCENARIO 11: SLP CPT QUESTION

I am evaluating an adult who has a traumatic brain injury and dysarthria. Which evaluation procedures and CPT codes may I use?

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SCENARIO 11: SLP CPT ANSWER You may code CPT 96125 for cognitive assessment

This is a timed, per hour code 31 minutes is allowable for one hour

OR You may code CPT 96105 for aphasia assessment

This is a timed, per hour code 31 minutes is allowable for one hour

If rationale to support both, then put -59 modifier on 96125 You may code CPT 92522 - Evaluation of speech sound production

(e.g., articulation, phonological process, apraxia, dysarthria) Document each procedure with results, interpretation,

recommendations, etc. 72

SCENARIO 11 CONTINUED: QUESTION

What if that dysarthria has a phonatory component?  In addition to the cognitive assessment and the speech-sound production evaluation, may I also add a voice evaluation and maybe also an acoustic and aerodynamic assessment?

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SCENARIO 11 CONTINUED: ANSWER

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RESOURCES

For Medicare, get in touch with the Medicare Administrative Contractor in your area. If you continue to have problems, please contact ASHA's health care economics and advocacy team at reimbursement@asha.org.

Notifications and news items will be available through ASHA Headlines and The ASHA Leader. Specific questions can be directed to ASHA's health care economics and advocacy team at reimbursement@asha.org.

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WHAT IS “SKILLED” TREATMENT?WHAT IS “NONSKILLED” TREATMENT?

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MEDICARE IMPROVEMENT STANDARD CLARIFICATION

CMS - “Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage.”

Jan 24, 2013 – Federal judge ruled CMS must allow coverage of therapy services that prevent or

slow deterioration Therapy services must require skilled care Coverage not dependent on potential for improvement Outpatient services, Inpatient rehab, SNF, home health Does not apply to CORFs b/c statue specifies “rehabilitative”

JIMMO V. SEBELIUS SETTLEMENT AGREEMENT

Coverage not dependent on potential for improvement, but rather on the need for skilled care

Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s abilities; e.g., carry out communication or feeding activities

Coverage is not available when the beneficiary’s maintenance care needs can be addressed safely and effectively through the use of nonskilled personnel (e.g., assistants, qualified personnel, caretakers or the patient).

See www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf

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PUB 100-02 MEDICARE BENEFIT POLICY, TRANSMITTAL 179 DATE: JANUARY 14, 2014

Skilled maintenance therapy may be covered whenPatient’s special medical complications or complexity of

the therapy procedures require skilled careAn individualized assessment of patient’s clinical

condition demonstrates that the specialized judgment, knowledge, and skills of a qualified speech-language pathologist are necessary for the performance of a safe and effective maintenance program to maintain the beneficiary at maximum practicable level of function

 http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R179BP.pdf

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PROFESSIONAL SKILLED TREATMENT “For patients with chronic or degenerative conditions,

evaluate patient’s current functional performance; provide treatment to optimize current functional ability, prevent deterioration, and/or modify maintenance program” (Medicare Benefit Policy Manual, Chapter 15, Section 220.2 C&D).

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WHAT DOES A PROFESSIONAL DO?

Practice at the TOP of our license Clinical decision-making – using expert knowledge Develop and modify treatment and maintenance

programs Train, instruct and supervise others

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PROFESSIONAL SKILLED TREATMENTSPECIFICS Analyze medical/behavioral data and select

appropriate evaluation tools/protocols to determine communication/swallowing diagnosis and prognosis.

Design plan of care (POC) including length of treatment; establishment of long- and short-term measurable, functional goals and discharge criteria.

Develop and deliver treatment activities that follow a hierarchy of complexity to achieve the target skills for a functional goal.

http://www.asha.org/Practice/reimbursement/medicare/Documentation-of-Skilled-Versus-Unskilled-Care-for-Medicare-Beneficiaries/

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PROFESSIONAL SKILLED TREATMENT Based on expert observation, modify activities during

treatment sessions to maintain patient motivation and facilitate success. Increase or decrease complexity of treatment task. Increase or decrease amount or type of cuing needed. Increase or decrease criteria for successful performance

(accuracy, number of repetitions, response latency, etc.). Introduce new tasks to evaluate patient’s ability to generalize

skill Conduct ongoing assessment of patient response in order

to modify intervention based on: patient performance in treatment activities; patient report of functional limitations and/or progress

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PROFESSIONAL SKILLED TREATMENT

Engage patients in practicing behaviors while explaining the rationale and expected results and/or providing reinforcement to help establish a new behavior or strengthen an emerging or inconsistently performed one

Develop maintenance program—to be carried out by patient and caregiver—to ensure optimal performance of trained skills and/or to generalize use of skills

Train patients/caregivers in use of compensatory skills and strategies (e.g., feeding and swallowing strategies, cognitive strategies for memory and executive function)

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OUTPATIENT SCENARIO: PATIENT CURRENTLY NOT RECEIVING THERAPY UNDER A THERAPY PLAN OF CARE

Patient with multiple sclerosis needs maintenance program to slow or prevent deterioration in communication ability caused by medical condition

Therapy services from qualified SLP may be covered to establish maintenance program even though patient’s current medical condition does not yet justify need for individual skilled therapy sessions

Evaluation, establishment of the program, and training family or support personnel may require the skills of a therapist and would be covered

NOTE: In this example, the skills of a therapist are not required to actually carry out the maintenance program services and, as a result, are not covered. 85

WHAT IS UNSKILLED CARE?

Unskilled services do not require the special knowledge and skills of an SLP Performance reporting without describing modification, feedback,

or caregiver training that was provided during session Repeating the same activities as in previous sessions without

noting modifications or observations Activities without rationale or connecting the tasks to goals Observing caregivers without providing education or feedback

and/or without modifying plan Recording observations of beneficiary without providing any

direct treatment strategies

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WHAT IS UNSKILLED CARE? Service can be self-administered Service may be furnished safely and effectively by an

unskilled person without direct or general supervision Service is related to activities for the general good and

welfare of patient (e.g., fitness, flexibility, motivation, diversion)

Therapist provides an important, yet nonskilled service in the absence or unavailability of a competent person

Service is NOT considered a skilled therapy service merely because the activity is provided by a qualified therapist

Ref: Pub 100-02 Medicare Benefit Policy, Transmittal 179 87

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MEDICARE RULE - USE OF SLP ASSISTANTS

Services of SLP Assistants NOT recognized for Medicare coverage

Therapy services provided by SLP Assistants, even if they are licensed to provide services in their states, will be considered unskilled services and denied as not reasonable and necessary

Check state law for what assistants can and cannot do in what settings (e.g., schools vs. health care)

Ref: Medicare Benefit Policy Manual, Ch15, 230.3 - Practice of Speech-Language Pathology, (Rev. 106, Issued: 04-24-09, Effective: 07-01-09, Implementation: 07-06-09)

MEDICARE RULE - USE OF SLP STUDENTS Medicare requires 100% personal supervision of SLP students by

qualified SLP in outpatient setting Must be in the room directing the service Must not be engaged in other activities

Student considered extension of qualified practitioner Qualified* SLP (for Medicare) meets one of the following

requirements: The education and experience requirements for Certificate of Clinical

Competence in SLP granted by ASHA; or Meets educational requirements for certification and is in process of

accumulating the supervised experience required for certification. Only services of qualified practitioner can be billed and paid This does NOT apply to non-Medicare settings unless specified

*qualified not always same definition for Medicaid

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DOCUMENTATION

How do you document to show skilled services?

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DOCUMENTATION SMART goals

SpecificMeasurableActionable/AttainableRelevant/ RealisticTime-bound

Focus on practical function Treatment notes and Progress Reports need to be

patient/client-specific and relevant

Ref for history of SMART goals: Doran, George T. “There’s a S.M.A.R.T. way to write management’s goals and objectives.” Management Review 70.11 (Nov. 1981): 35.Business Source Corporate. EBSCO . 15 Oct. 2008. 91

DOCUMENTATION - FUNCTIONAL GOAL WRITING Long Term Goals – Developed for entire episode of care

Measureable and specific to the identified functional impairment

When episode is anticipated to be longer than one certification period (90 days), LTG may be specific to current certification period

Short Term Goals – Developed for week or month of therapy Help to track progress toward LTG for episode of care The “what” and “why”

Treatment Objectives Treatment strategies and activities The “how”

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DOCUMENTATION - REFLECT THE VALUE OF SLP CARE Descriptions and rationale of skilled treatment

intervention strategies Changes made to treatment due to assessment of

patient’s needs on a particular treatment day Modification of treatment tasks and rationale due to

patient’s progress or regression Reasons for lack of progress and the justification for

continued treatment if treatment continues after regression or plateau

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DOCUMENTATION – WHAT NOT TO WRITE

Vague or subjective descriptions of the patient’s care Terminology that would not adequately describe the

need for skilled care: Continue with POC Patient tolerated treatment well Patient remains stable

Such phraseology does not provide a clear picture of the results of treatment, nor “next steps” that are planned.

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IF IT WAS NOT DOCUMENTED, IT WAS NOT DONE!

Documentation serves as the means by which a provider may establish and a Medicare contractor or auditor may confirm that skilled care is, in fact, needed and received

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RESOURCES

 http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R179BP.pdf

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf

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ASHA RESOURCESSKILLED VERSUS UNSKILLED TREATMENT

“Documentation of Skilled Versus Unskilled Care for Medicare Beneficiaries”

http://www.asha.org/Practice/reimbursement/medicare/Documentation-of-Skilled-Versus-Unskilled-Care-for-Medicare-Beneficiaries/

“Examples of Documentation of Skilled and Unskilled Care for Medicare Beneficiaries”

http://www.asha.org/Practice/reimbursement/medicare/Examples-of-Documentation-of-Skilled-and-Unskilled-Care-for-Medicare-Beneficiaries/

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2014CAPCSD ANNUAL MEETING

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THANK YOU VERY MUCH!

After Lunch – Part Two: Reimbursement Update with Dr. Bob Fifer