DISPELLING MEDICARE MYTHS

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Franklin Davis
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1 DISPELLING MEDICARE MYTHS ASHA Convention 2008 MICS Network (ASHA s Medicare Intermediary-Carrier State Network) 1 STORYTELLERS Joanne Wisely, MA CCC/SLP ACE MICS Representative Pennsylvania Joanne.Wisely@GenesisHCC.com Mary Casper, MA, CCC-SLP, BRS-S MICS Representative Ohio MCASPER@hcr-manorcare.com Mark Kander MICS Staff Coordinator, ASHA mkander@asha.org THE LEGEND Long ago, in a land not so far away lived an evil wizard named Hikfa (HCFA). So evil was this wizard that he had to change his name to enter any part of the land. His new name became See-a-mess (CMS). See-a-mess created all sorts of scary things. First, there was the Pea Pea Ess(PPS) and then the Fee Skedule (Fee Schedule). These were followed by the villainous Thera-pea Kap (Therapy Cap). Around the time of the Fee Skedule creation, several myths emerged.. 3

org THE LEGEND Long ago, in a land not so far away lived an evil wizard named Hikfa (HCFA). So evil was this wizard that he had to change his name to enter any part of the land.

2 THE MYTHS See-a-mess seemed so entrenched in creating confusion for those around him, myths emerged from his existence. These came to be known as the General Myths, the Coding Myths and the Service Myths. After many years of being considered evil, the villagers felt sorry for See-a-mess. They realized that he was a wizard who had only created some misguided spells that proved unsuccessful. His evil doing was no longer feared. The myths surrounding his power were dispelled 4 PURPOSE OF THIS STORY Once all myths are dispelled, you will: Understand the difference between coding guidance and billing requirements Know how to obtain clarification to properly code and bill for SLP services Identify the appropriate codes to describe and support several SLP services 5 THE MYTHS and THE TRUTHS 6

They realized that he was a wizard who had only created some misguided spells that proved unsuccessful. His evil doing was no longer feared.

3 GENERAL MYTHS CMS Determines All Medicare Policies Medicare is an entitlement program administered by CMS Medicare is interpreted locally by Fiscal Intermediaries (FIs), Medicare Administrative Contractors (MACs), Medicare replacement policies and/or other insurance companies 7 GENERAL MYTHS All Part B Coverage Policies Apply to Part A Coverage of the inpatient or home health stay takes precedence over coverage of treatment sessions CMS is currently reviewing Part B policies that may officially apply to Part A patients 8 GENERAL MYTHS Medicare Part A and Medicare Part B have the same rules about SLP service provision. See the next slide for explanation of coverage and differences 9

Coverage of the inpatient or home health stay takes precedence over coverage of treatment sessions CMS is currently reviewing Part B policies that may officially apply to

4 Medicare Part A vs. Medicare Part B Medicare Part A Hospital Insurance Care in Hospital Care in Skilled Nursing Facility Home Health Hospice Care Medicare Part B Medical Insurance Doctor bills Outpatient Hospital Various other medical services not covered by Part A CODING MYTHS ALL payers use the same codes for ALL SLP services. Each Medicare fiscal intermediary/mac has the authority to determine Local Coverage Determinations (LCDs) Managed Care and Private Insurance Plans are not required to adhere to the same coding and coverage policies as Medicare fiscal intermediaries/macs 11 CODING MYTHS SLPs cannot use Physical Medicine Codes to bill for SLP services CPT code and are in all fiscal intermediary/mac LCDs Highmark Medicare Services is the only MAC to include 97110, and as acceptable for SLP services 12

Various other medical services not covered by Part A CODING MYTHS ALL payers use the same codes for ALL SLP services.

5 CODING MYTHS SLP evaluation codes cannot be used for re-evaluations. There are no re-evaluation codes for SLP services CPT and should be used for both an evaluation and a re-evaluation, unless otherwise specified by the payer Medicare has provided criteria for a re-evaluation (CMS Benefit Policy Manual, Chap 15, 220.A - ) 13 SERVICE MYTHS SLP or Dysphagia evaluations should be limited to 15 minutes Duration of evaluations and services must be reasonable within acceptable standards of practice (CMS Benefit Policy Manual Chap 15, Section B) You need sufficient information to develop a meaningful Plan of Care Medicare Part A Prospective Payment System (skilled nursing facilities) pays a daily RUG rate, based on the patient s acuity (rehab treatment minutes & skilled nursing needs) 14 SERVICE MYTHS An SLP and Dysphagia evaluation cannot be billed on the same day There are no CCI edits that restrict SLPs from providing these two evaluations on any one day See the CCI edits on ASHA s web site: _edits_slp.htm 15

for a re-evaluation (CMS Benefit Policy Manual, Chap 15, 220.A - http://www.cms.hhs.gov/manuals/downloads/bp102c15.

6 SERVICE MYTHS An SLP and Dysphagia treatment session cannot occur on the same day. There are no CCI edits that prohibit these sessions from being billed on the same day For a list of all CCI edits, see the link to ASHA s web site on the previous slide 16 SERVICE MYTHS An aphasia evaluation cannot be billed after a speech and language evaluation has been billed. SLPs are required to accurately code for the services provided The SLP determines when an comprehensive aphasia evaluation is needed to supplement and support the speech-language evaluation When an aphasia evaluation is completed, document the reason for and type of (ex: BDAE, WAB ) test being used 17 SERVICE MYTHS SLPs may not use Standardized Cognitive Performance Testing (CPT 96125) code because it is part of the speech and language evaluation. Document need for the cognitive testing/evaluation A standardized test may be normreferenced or criterion-referenced 18

evaluation cannot be billed after a speech and language evaluation has been billed.

7 SERVICE MYTHS SLP alone cannot qualify ( skill ) a patient for coverage of a Medicare SNF stay. The medical needs of the patient determine the need for placement in a SNF The need for any rehabilitation discipline on a five day per week basis may necessitate skilled care whether it be cognition, swallowing, and/or communication disorders 19 SOURCE WIZARDRY Where to find information click on Medicare or "Coding for Reimbursement Coding for Reimbursement on ASHA web site-*: Medicare CPT coding Rules Correct Coding Initiative (CCI) Edits Voice evaluation & tx Electrical stimulation Auditory & aural stimulation Medicare fee schedule 20 SOURCE WIZARDRY Medicare Provider Resources and Regulations Medicare Benefit Policy Manual, Chapter c15.pdf scroll to sections: Plans of Care Certification& recertification Documentation requirements SLP services 21

cognition, swallowing, and/or communication disorders 19 SOURCE WIZARDRY Where to find information www.asha.

8 SOURCE WIZARDRY Medicare Claims Processing Manual, Chapt c05.pdf 20 Applicable rehabilitation codes 20.1 Coding modifiers 20.2 Coding units minute codes Medicare Learning Network 22 SOURCE WIZARDRY LCDs on your intermediary or MAC's web site: Look under Medical Policy or Medical Review May be separately listed as Local Coverage Determination Locating your MAC s web site: Downloads/02_ICdirectory.pdf 23 SOURCE WIZARDRY ASHA Medicare Intermediary-Carrier State Network (MICS) Find your state representative at: /medicare/mics 24

gov/mlnmattersarticles/ 22 SOURCE WIZARDRY LCDs on your intermediary or MAC's web site: Look under Medical Policy or Medical Review May be separately listed as Local Coverage

9 HELP DISPEL THE MYTHS! The MICS needs a state association-appointed member in: AL CO CN DE DC GA HI ME MA NH NM ND OR RI UT VT WV WY QUESTIONS 26 CONTACTS Questions to ASHA s Health Care Economics & Advocacy team should go to: Reimbursement@asha.org Mark Kander mkander@asha.org For state or local Medicare questions go to: Your MICS representative (as available) or your state speech and language association 27

WY QUESTIONS 26 CONTACTS Questions to ASHA s Health Care Economics & Advocacy team should go to:

Medicare Outpatient Therapy Billing

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services R Medicare Outpatient Therapy Billing August 2010 / ICN: 903663 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare