what you need to know before heading to a medical placement presenters: beryl fogel, ma, ccc-slp,...
TRANSCRIPT
What You Need to Know Before Heading to a Medical
Placement Presenters:
Beryl Fogel, MA, CCC-SLP, Linda K Pippert, MA, CCC-SLP, Debra Ouellette, MS, OTR-L, SCLV
CSHA Annual Convention, Long Beach, California
Friday, March 6, 2015
Disclaimer Statement:Financial Disclaimers:
None of the presenters are being paid for this presentation.
None of the presenters has a financial interest in any of the materials referenced in this presentation.
Non-financial Disclaimer: Beryl Fogel and Linda Pippert serve on the board of directors for the California Speech-Language Hearing Association.
Why do we bother to do this presentation?
Expectations: Knowledge in these areas:
Regulations
Billing
Documentation
Teamwork
Best Practices
Performance Expectations and Standards
Be a valuable contributor to the organization
In-depth knowledge beyond your profession includes the facility, organization and the health care industry
Remain current with professional knowledge to perform essential job functions and carry out responsibilities
Performance Expectations and Standards
Mission,Values,Vision
Mission: Reason the organization exists – Core purpose
Values: What the organization believes in – Will not change
Vision: What the organization strives to be – Future milestones
Performance Expectations and Standards
Facility-specific policies and procedures (P&Ps)
System-wide P&Ps apply to all employees
Discipline-specific P&Ps must comply with:
ASHA scope of practice
CA state licensing regulations
ASHA code of ethics
Performance Expectations and Standards
How you present yourself as an employee is key to how you are perceived by others
Facility-specific rules apply to: Timeliness – may actually mean arriving early Dress code – includes, hair, nails, makeup, tattoos Behavior toward colleagues – no matter what job
they hold Willingness to work/assist outside your job title –
in a rehab or home health setting, you may need to take your patient to the bathroom
Eagerness to learn additional required skills – includes, blood pressure monitoring in a medical setting
Regulations/Billing Definitions of CMS, DHS, Medicaid/Medi-
Cal, Medicare Audits Patient Protection and Affordable Care
Act: New Autism info: Health Insurance Portability and
Accountability Act (HIPAA) (1996, 2013)
Regulations/Billing
Definitions
CMS Centers for Medicare and Medicaid
Services: Previously was known as the Health Care Financing Administration (HCFA) - CMS is responsible for the administration of many key federal health care programs. It is part of the Department of Health and Human Services. They oversee Medicare, Medicaid, Children’s Health Insurance Program (CHIP); the Health Insurance Portability and Accountability Act (HIPAA), among other services.
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Medicaid/Medi-Cal Government programs managed by CMS. A
social welfare program. It is provided to certain individuals and families with low incomes and few resources. Primary oversight is at the federal level but :
-Each state establishes its own eligibility standards
-Each state determines the type, amount, duration, and scope of services.
-Each state sets the rate of payment for services
-Each state administers its own Medicaid program.
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Medicaid There are mandatory services that the federal
government states must be provided by the states to receive matching funds. To review a few:
- Inpatient Hospital Services
- Outpatient Hospital Services
-Nursing facility services for persons aged 21 and older
-Home Health care for those eligible for skilled nursing services
-Physician Services 12
Medicaid Some services are optional and will receive Federal
matching funds if the state decides to provide them. They include:
-Optometrist services and eyeglasses
-Rehabilitation and physical therapy services
-Transportation services
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Medi-Cal California’s Medicaid welfare program
serves low income families, seniors and
persons with disabilities,
children in foster care,
pregnant women, and certain low-income adults.
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Medi-Cal Jointly administered by
California Department of Health Care Services (DHCS)
CMS
In California, services are administered at the local level by the county welfare departments.
NOTE: Medi-Cal transitioned to a Medi-Cal Managed Care system, except for the dental benefits and mental health benefits of seriously and persistently mentally ill.
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Medicare Federal government insurance program
Established in 1965, under Title XVIII, Health Insurance for the Aged and Disabled, of the Social Security Act
Administered by the Social Security Administration
Benefits include speech-language pathology and audiology
Benefit programs are divided into four parts
SLPs and audiologists deal mainly with A & B 16
Medicare Part A
Medicare A: Hospital Insurance program * Pays for inpatient hospital stays; * Home health care (PT, OT, ST, Nursing). * Care in a skilled nursing facility (SNF) and certain equipment such as walkers, wheelchairs . * Acute hospital under PPS (prospective payment system).
Each case under a DRG - Diagnostic Related Group: Payments are weighted by the average resources used to treat Medicare patients in that DRG.
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Medicare Part BMedicare B: Supplementary Medical Insurance (SMI)
* Doctor visits
* Out-patient hospital visits and out-patient therapy
* Home health care
* Services in non-institutional settings, including diagnostic services (e.g., audiology), private
practice ST OT/PT, DME (durable medical equipment), prosthetics & orthotics
* In-patients in hospitals and SNFs when beneficiary is ineligible for Part A, or when Part A benefits
have expired
Optional program with monthly premium paid by beneficiary
Automatic Manual Review : $3700..KX modifiers 18
Medicare Eligibility
Medicare is a federally-funded program designed for
Persons at least 65 years old
Under 65 and disabled
U.S. citizens, or
Permanent legal residents for 5 continuous years and is eligible for Social Security benefits with at least ten years of payments contributed into the system
Any age with End-Stage Renal Disease (ESRD)(permanent kidney failure that requires dialysis or a transplant). 19
Medicare Funding
Funding:
Through payroll taxes Federal Insurance Contributions Act (FICA)
Self-Employment Contributions Act
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DHCS/DHS The Department of Health Care Services
Department of Health Services
Integrated system of providers, clinics, and hospitals. It is established to provide access to affordable care.
Oversees Medi-Cal
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Regulations/Billing Audits: RAC Audits: Recovery Audit Contractors
Audits; Medicare Audits. Developed to fight fraud, waste and abuse
in the Medicare program.
In 2006, the Tax Relief and Health Care Act required a national Recovery Audit Contractor (RAC) program to i.d. improper payments made on claims for services paid for by Medicare. (They are for both under- and over-payment)
RAC Audits Country is divided into 4 regions.
Each region has its own contractor performing the audits.
What do they look at:
They may ask for medical record charts going back to 2007
Items typically requested:
Physician Orders
Care Plans
Therapy Evaluations, Notes, Progress Reports, Discharge Summaries
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RAC Audits The “provider” has 45 days in which to respond The
“provider” may ask for an extension to provide records.
If overpayment is felt to have occurred,
CMS sends a Payment Demand Letter.
The provider may use the appeals process
The provider must demonstrate why the original
determination was incorrect.
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Certified Error Rate Testing Audits (CERT)
Done annually by CMS using a statistically valid random sample of claims.
Auditors review the selected claims to determine whether they were properly paid under Medicare coverage, coding and billing rules.
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Probe Audits Targeted at a particular service or specialty.
If a facility is chosen, auditors pull a sample of submitted claims for review prior to payment. If more documentation is needed they will request it with a deadline.
Failure to comply or you do not support what was billed, you do not receive payment for services. If they find anything that might be fraudulent, your Medicare Administrative Contractor (MAC) will refer the case to the appropriate agency for investigation.
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Audits Any payor may ask to review charts at anytime
Red Flags:
Illegible signatures
Not putting your credentials
Insufficient Documentation to support services
Billing for one-on-one when pt was in a group
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HIPAA Health Insurance Portability and
Accountability Act of 1996
-Recently updated and modified in 2013, by the Department of Health and Human Services and is mandatory
-The goal of the law is to make it easier for people to keep health insurance, protect patient confidentiality, reduce fraud, and protect confidential medical information.
Coverage has been expanded to subcontractors and business associates
Government now has the ability to enforce the law28
HIPAA Divided into 2 Main Sections: Portability & Administration
Simplification
Title I: Portability: Protects health insurance coverage for people who lose or change jobs.
Title II: Administration Simplification: Standardization of health care information systems, (Electronic Healthcare Technology) and PRIVACY!
When going into a medical site you will be required to complete HIPAA training for the facility to maintain compliance and to insure that you maintain compliance with all privacy and confidentiality guidelines (every facility has a compliance or privacy officer). 29
ACA Patient Protection and Affordable Care Act (2010)
AKA: “ObamaCare” or Federal Healthcare Reform
Passed by Congress and signed into law by President Obama on March 23, 2010.
U.S. Supreme Court upheld the law in a final decision on June 28, 2012.
Designed to provide more Americans with affordable healthcare insurance, improve the quality of healthcare, and to curb the growth of healthcare spending in the U.S.
Expands eligibility for Medicaid and developing health insurance marketplaces.
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ACAPatient’s Bill of Rights
Protections that apply to health coverage
Coverage
Costs
Care
Consumers are in charge of their health care
Stability
Flexibility
ACA Patient’s Bill of Rights
Coverage
Ends pre-existing condition exclusions for children
Keeps young adults covered
Covered under parent’s health plan to age 26
Ends arbitrary withdrawals of insurance coverage
Guarantees the right to appeal
ACAPatient’s Bill of Rights
Costs
Ends lifetime limits on coverage
Reviews premium increases
Helps you get the most from your premium dollar
ACAPatient’s Bill of Rights
Care
Covers preventive care at no cost to you
Protects your choice of doctors
Removes insurance company barriers to emergency services
Rehabilitation
• Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.(US Dept of Health and Human Services)
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Habilitation Habilitation Services: California Definition:
Medically-necessary health care services and health care devices that assist an individual in partially or fully acquiring or improving skills and functioning and that are necessary to address a health condition, to the maximum extent practical. These services address the skills and abilities needed for functioning in interaction with an individual's environment. (In other words, health care services that help a person get back or improve skills and functioning for daily living.)
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Regulations/Billing Patient Protection and Affordable Care Act: CMS delegated to the states the authority to
define coverage requirements for habilitative services with little additional direction.
CMS did say that rehabilitation services should be covered separately from and in addition to habilitation services; and maintenance of function should be a component of habilitative services coverage.
California has not designated set limits as of now for PT/OT/ST as other states have.
Regulations/Billing Medicaid Services to Children with
Autism Therapy is covered for individuals with Autism
under age 21 CMS and CHIP (Children’s Health Insurance Plan)
has provided states with federal guidelines on Medicaid coverage of therapies
Written primarily for autism services, it clarifies services provided by SLPs and Auds to individuals with other diagnoses
Focuses guidance on applied behavior analysis (ABA), but acknowledges other treatments
Regulations/Billing Health Insurance Portability and Accountability
Act (HIPAA) (1996, 2013)
Deals with Privacy and Security of patient health information and also amended in 2013 to include HITECH Act, for high tech security
What does it mean to you?
Documentation:
Coding: What do we code? Diagnosis: International Classification of
Diseases ICD-9, ICD-10
“Procedures”: Current Procedural
Terminology: CPT Evaluation and treatment
Patient Status: G-codes Status of the patient at the beginning of care, at
reportable progress interval, end of care
Billing Codes (Used by the facility)
Documentation: ICF and ICD
Partner Classification Systems ICF (International Classification of Functioning, Disability,
and Health
Developed and published by World Health Organization in 2001
System of classification for health and health-related conditions for children and adults
Classifies functioning
ICD (International Classification of Diseases and Related Health Problems) used in U.S. and abroad
Classifies disease
Documentation:CPT Codes
Current Procedural Terminology (CPT)
Codes used to describe the services provided by health care professionals to third party payers
“CPT codes are valued for reimbursement by the federal government’s Medicare program.” http://www.asha.org/Practice/reimbursement/Module-One-Transcript/
Documentation:
Coding: Who “owns” the codes?
AMA owns the diagnosis codes AND the procedure codes!
Documentation: ASHA, AOTA, APTA all have representatives who sit
on the AMA Committee which oversee the development and use of the coding systems.
ASHA produces an annual document available on the ASHA web site:
Current Document:
“2014 ICD-9-CM Diagnosis Codes: Related to Speech and Hearing Disorders.”
Documentation: Diagnostic Codes
ICD-9, ICD-10 International Classification of Diseases WHO: World Health Organization ICD-9s are owned by AMA
Documentation: Diagnostic Codes
ICD-9s
Medical Diagnosis: Diagnosis given by the physician
Treatment Diagnosis: Diagnosis given by the SLP
Documentation: Diagnostic Codes
ICD-9s Commonly Used by SLPs (examples)
Medical Diagnosis: Physician’s diagnosis331.0 Alzheimer’s Disease 787.20-787.29 Dysphagia331.1 Frontotemporal dementia 332 Parkinson’s Disease333.4 Huntington’s Chorea 340 MS 348.1 Anoxic Brain Damage431 Intracerebral hemorrhage435 TIA 436 CVA507 Pneumonia
Documentation: Diagnostic Codes
ICD-9s Commonly Used by SLPs Treatment Diagnosis: SLP’s diagnosis
315.3 Developmental speech or language disorder
438 Late effects of CVA: 438.0 Cognitive Deficits 438.10 Speech and language deficits,
unspecified 438.11 Aphasia 438.12 Dysphasia 438.13 Dysarthria 438.8 Apraxia 1438.82 Dysphagia
Documentation: Diagnostic Codes
ICD-9 Treatment Diagnostic
Code(s) used by the SLP,
MUST relate to a Physician’s Medical
Diagnosis!!!
Documentation: Procedure Codes
Current Procedure Terminology (CPTs)CPTs commonly used by SLPs: Basic codes
92507 Speech Therapy
92508 Group Treatment
Documentation: Procedure Codes
Current Procedure Terminology (CPTs)CPTs commonly used by SLPs: Speech/Language and Voice
Evaluations92521 Evaluation of Fluency
92522 Evaluation of Speech Sound Production
92523 Evaluation of speech sound production with evaluation of language comprehension and expression
92524 Behavioral and qualitative analysis of voice and resonance
92527 Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech
Documentation: Procedure Codes
Current Procedure Terminology (CPTs)CPTs commonly used by SLPs: AAC92605 Evaluation for prescription for non-speech
generating AAC device, face-to-face with the patient;
first hour
92606 Therapeutic services for use of non-speech generating devices, including programming and modification
92607 Evaluation for prescription for speech-generating AAC device, first hour
92608 Evaluation [92607], each additional 30 minutes
Documentation: Procedure Codes
Current Procedure Terminology (CPTs)CPTs commonly used by SLPs:
Dysphagia92610 Dysphagia Evaluation (bedside)
92611 Motion Fluoroscopic evaluation of swallowing function by cine or video recording (MBSS)
92612 Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording (FEES)
92616 Flexible fiberoptic endoscopic evaluation of swallowing and sensory testing by cine or video recording (FEESST)
92526 Dysphagia Treatment
Documentation: Procedure CodesCurrent Procedure Terminology (CPTs)
CPTs commonly used by SLPs: Aphasia96105 Assessment of Aphasia (includes
assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading spelling, writing, eg by BDAE, WAB, etc)
Documentation: Procedure CodesCPTs commonly used by SLPs:
Developmental
96111 Developmental testing, (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized development instruments) with interpretation and report
96125 Standardized cognitive performance testing (eg RIPA, ABCD, etc) per
94532 Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes. (Cognitive Treatment)
Documentation:
HCPCS: Healthcare Common Procedure Coding System
Codes used by the facility to bill the Medicare system
CPTs are used to code therapy billing.
Documentation: G-Codes:
Initial: Status of the patient at the initial evaluation.
Progress: Status of the patient at the progress report interval.
Discharge: Status of the patient at the end of care.
CMS recognizes the ASHA NOMS coding system for reporting the G-Codes.
ASHA has a “equivalent” that is used when reporting these.
Documentation: G-Codes
Swallowing G-code Set Motor Speech G-code Set Spoken Language Comprehension G-code Set Spoken Language Expressive G-code Set Attention G-code Set Memory G-code Set Voice G-code Set Other Speech Language Pathology G-code
Set
Documentation: G-Codes
Swallowing G-code Set G8996 Swallow Current Status G8997 Swallow Goal Status G8998 Swallow D/C Status
Motor Speech G-code Set G8999 Motor Speech Current Status G9186 Motor Speech Goal Status G9158 Motor Speech D/C Status
Documentation: G-Codes
Attention G-code Set G9165 Atten Current Status G9166 Atten Goal Status G9167 Atten D/C Status
Memory G-code Set G9168 Memory Current Status G9169 Memory Goal Status G9170 Memory D/C Status
Documentation: G-Codes
Voice G-code Set G9171 Voice Current Status G9172 Voice Goal Status G9173 Voice D/C Status
Other Speech Language Pathology G-code Set
G9174 Speech Lang Current Status G9175 Speech Lang Goal Status G9176 Speech Lang D/C Status
Documentation: G-Codes Modifiers:
Modifier Impairment Limitation Restriction ASHA NOMS
CH 0 percent impaired, limited or restricted. 7
CI At least 1 percent but less than 20 percent impaired, limited or restricted. 6
CJ At least 20 percent but less than 40 percent impaired, limited or restricted. 5
CK At least 40 percent but less than 60 percent impaired, limited or restricted. 4
CL At least 60 percent but less than 80 percent impaired, limited or restricted. 3
CM At least 80 percent but less than 100 percent impaired, limited or restricted. 2
CN 100 percent impaired, limited or restricted. 1
Documentation
Important: “If your required Medicare paperwork has any errors your payment may be in jeopardy.”
(Lisa Satterfield,ASHA Director of Health Care Regulatory Advocacy,& Gennith Johnson,ASHA Associate Director of Health Care Services; Bottom Line: Document it Correctly with this Glossary. The ASHA Leader July 2013, Vol.18, 24-25.doi:10.1044/leader.FTJ7.18072013.34)
DocumentationGlossary
Information in the medical record must be consistent with information on the claim
Evaluation: “Comprehensive service that requires professional skills”
Re-evaluation: “Billable when an assessment indicates a significant change in patient condition that was not anticipated in the plan of care”
o Satterfield, L. & Johnson, G., Bottom Line: Document it Correctly with this Glossary. The ASHA Leader July 2013, Vol.18, 24-25.
DocumentationGlossary
Assessment
Not an evaluation per Medicare terminology
No separate billing code
Skilled service provided by a clinician during treatment
Clinical judgment regarding progress toward goals or need for re-evaluation
Clinician uses clinical observation, patient self-report, objective data
DocumentationGlossary
Plan of Care (POC)– Written treatment plan
Establish POC prior to initial treatment session
Consistent with and part of current evaluation
Long-term treatment goals
Type, amount, duration, & frequency of therapy services
Separate plan for each therapy discipline (ST, OT, PT)
DocumentationGlossary
Certification/Recertification
Approval of plan of care from physician or nonphysician practitioner
Must be received within 30 days of initial treatment
Requires dated signature on POC, or on other document designed for this purpose
Recertification required every 90 days if POC does not change significantly
Recertification required every 30 days if POC significantly modified
Documentation Glossary
Functional Reporting
Medicare Part B claims requirement initiated in in 2013
SLPs and all other providers required to report nonpayable G-Codes and related information
G-Codes and modifiers must be included in POC and in progress notes
DocumentationGlossary
Progress Notes
Provide ongoing justification for medical necessity and skilled service by SLP
Required by Medicare at least once very 10 treatment days
Assessment of improvement and/or extent of progress, continuing or revisions to treatment plans, results of additional evaluations, modifications to short- or long-term goals
DocumentationGlossary
Discharge Note
Final progress note
Last opportunity to justify medical necessity
If discharge is unanticipated, may review treatment notes, and request verbal reports from qualified personnel
DocumentationGlossary
Treatment Day
Single calendar day
Treatment, evaluation, and/or re-evaluation
Multiple visits or treatments/encounters may occur
Treatment Notes – “Daily Notes”
Record for each treatment day includes, skilled intervention, service provided, date, total time of service, treatment provider signature
Medicare has no requirements for a standard format
Documentation Glossary
Skilled Therapy Services
The ONLY services that may be billed under Medicare
CANNOT be provided independently by assistants, qualified personnel, caretakers or the patient/client
Must meet two criteria:
Provider is a qualified professional and documents in the POC and progress notes
“They require the expertise, knowledge, clinical judgment and decision-making abilities of a clinician for safe and effective results.”
o Satterfield, L. & Johnson, G., Bottom Line: Document it Correctly with this Glossary. The ASHA Leader July 2013, Vol.18, 24-25.
DocumentationGlossary
Unskilled services:
Repetitive
Reinforce previously learned skills,
Maintain function in a maintenance program
Documentation Standards
Functional: What do we mean by functional? - Patient/client-focused- Meaningful goals for patients/clients to
return to”their life”- Know what your patient/client participated in prior to their current
situation KNOW: WHO THEY ARE.
Documentation Standards
What do we mean by functional? How is what we are working on
preparing them for going
Home
Assisted Living facility
More intense rehab setting
Documentation Standards
What do we mean by functional? What activities are important to the
individual and the family/caregiver? Auditory Comprehension: Whose directions do they need to
follow? What kind of auditory input do they need to attend to and act upon?
While in rehab/hospital, at home, …. Verbal Expression: Speaking with family, medical staff,
other caregivers Reading: Community signs, books, the newspaper Writing: Signing checks, writing e-mails to family members,
preparing a shopping list Cognitive: Responsible for finances, responsible for cooking
meals, responsible for taking care of their home/apartment
Documentation Goals
Your goals should reflect a logical plan based on your evaluation findings and when documenting daily toward the goals there should be a reflection of “how” what you did is working toward the improvement of an impairment or functional limitation.
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Documentation Goals
Goals may target:
Patient’s ability to organize and manage medications in a pill organizer for the ability to independently complete daily medication management
Patient’s use of a phone calendar for self-time management and independence in daily life tasks/appointments
SLP, OT and other team members participate in discipline-appropriate aspects of a patient’s goal
Documentation Long-term goals are written with the time frame of their
treatment at your facility.
Short-term goals are written with the time frame of when a progress report will be written.
May be a week, two weeks, one month.
Medicare Part-B, every 10 treatment days.
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Documentation Standards:
Teamwork: How do we work together with:-P.T.-O.T.-S.T.-Neuropsych-Nursing-Social Work-Physician-Dietary-Respiratory-Recreational Therapy
Conference Meetings Non-billable time for Medicare A, but important
“team” time.
Medicare A for inpatient IRF’s requires every patient has a team conference lead by a physician every 7 days beginning from the date of admission.
At this time talk about status, barriers, insure that all hours are met within timeline per Medicare. ( Must meet 15 hours per week in a consecutive 7 days, may not make up time for that week in another week).
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Productivity:
Ethics in Practice Reporting Fraud Teamwork
EBP: ASHA Practice Portal
How to use the ASHA Practice Portal to provide EBP…
www.asha.org Search button:
Enter an area that you want info on, eg aphasia, apraxia
OR Enter “practice portal”
What Else Do you wonder about? Q/A
Contact Info:
Beryl Fogel, [email protected]
Linda K Pippert, [email protected]
Debra Ouellette, [email protected]
