Case Scenaris and Sample Claim Frm Entries fr Outcmes Reprting fr Medicare Part B Therapy Services The American Speech Language Hearing Assciatin develped the fllwing scenaris t help speech language pathlgists understand the claims prcess when reprting utcmes fr Medicare Part B therapy services. Fr mre infrmatin n claims based utcmes reprting, g t www.asha.rg/practice/reimbursement/medicare/claims Based Outcmes Reprting fr Medicare Part B/. Fr questins, cntact ASHA s health care ecnmics and advcacy team at reimbursement@asha.rg. Scenaris Scenari 1: Patient Seen fr One Functinal Limitatin 2 Scenari 2: Patient Seen fr Multiple Functinal Limitatins 4 Scenari 3: Patient Seen fr Evaluatin and Treatment Nt Recmmended 7 Scenari 4: Patient Seen fr Evaluatin and Referred fr Treatment 8 Scenari 5: Patient Seen fr Maintenance Therapy 10 American Speech Language Hearing Assciatin 1
Scenari 1: Patient Seen fr One Functinal Limitatin Functinal limitatin: Mtr Speech (G cde: G8999), FCM Level 2 (Mdifier: CM) Prjected Gal: Mtr Speech (G cde : G9186), FCM Level 7 (Mdifier CH) Reprting n the Initial Claim (Nte: The Mtr Speech reprting cdes are nt sequentially numbered) Line 1: CPT/HCPCS: 92522, Mdifier:GN Line 2: CPT/HCPCS: G8999, Mdifier: GN, CM (Current status f mtr speech limitatin) Line 3: CPT/HCPCS: G9186, Mdifier: GN, CH (Prjected gal fr mtr speech limitatin) Reprting n the Claim fr Visits #2 #9 Line 1: CPT/HCPCS: 92507, Mdfier: GN N additinal utcme/gal reprting Reprting n the Claim fr Visit #10 (Reprting must ccur at least nce every 10 treatment days) Line 1: CPT/HCPCS: 92507, Mdifier: GN Line 2: CPT/HCPCS: G8999, Mdifier: GN, CI (Current status f mtr speech limitatin) Line 3: CPT/HCPCS: G9186, Mdifier: GN, CH (Prjected gal fr mtr speech limitatin) Scenari cntinued n the next page American Speech Language Hearing Assciatin 2
Reprting n the Claim fr Final Visit (Patient discharged frm plan f care) Line 1: CPT/HCPCS: 92507 and/r 92522 (see nte belw) Line 2: CPT/HCPCS: G9158, Mdifier: GN, CH (Status f mtr speech limitatin at discharge) Line 3: CPT/HCPCS: G9186, Mdifier: GN, CH (Status f prjected mtr speech gal at discharge=gal met) ASHA Nte: Final visit may include treatment (92507) and/r re evaluatin (92506). The Medicare Benefit Plicy Manual (www.cms.gv/regulatins and Guidance/Guidance/Manuals/dwnlads/bp102c15.pdf [PDF]) states that a re evaluatin may be apprpriate prir t planned discharge fr the purpse f determining whether gals have been met, r fr the use f the physician r the treatment setting at which treatment will be cntinued. American Speech Language Hearing Assciatin 3
Scenari 2: Patient Seen fr Multiple Functinal Limitatins Functinal Limitatins: Swallwing (G cde: G8996), FCM Level 2 (Mdifier: CM) Spken Language Cmprehensin (G cde: G9159), FCM Level 2 (Mdifier: CM) Spken Language Expressin (G cde: G9162), FCM Level 1 (Mdifier: CN) CMS allws the reprting f ne functinal limitatin at a time. Fr this case, it was determined that Swallwing was the mst clinically relavent and wuld be reprted initially. Prjected Gal: Swallwing (G cde G8997), FCM Level 6 (Mdifier: CI) Reprting n the Initial Claim Line 1: CPT/HCPCS: 92610, Mdifier: GN Line 2: CPT/HCPCS: G8996, Mdifier: GN, CM (Current status f swallwing limitatin) Line 3: CPT/HCPCS: G8997, Mdifier: GN, CI (Prjected gal fr swallwing) Line 4: CPT/HCPCS: 92523, Mdifier: GN Line 5: CPT/HCPCS: G9159, Mdifier: GN, CM (Current status f spken language cmprehensin) Line 6: CPT/HCPCS: G9160, Mdifier: GN, CI (Prjected gal fr spken language cmprehensin) Line 7: CPT/HCPCS: G9161, Mdifier: GN, CM (Discharge fr spken language cmprehensin) Reprting n the Claim fr Visits #2 #9 Line 1: CPT/HCPCS: 92507, Mdfier: GN Line 2: CPT/HCPCS: 92526, Mdifier: GN N additinal utcme/gal reprting Scenari cntinued n the next page American Speech Language Hearing Assciatin 4
Reprting n the Claim fr Visit #10 (Reprting must ccur at least nce every 10 treatment days) Line 1: CPT/HCPCS: 92507, Mdifier: GN Line 2: CPT/HCPCS: 92526, Mdifier: GN Line 3: CPT/HCPCX: G8996, Mdifier GN, CK (Current status f swallwing limitatin) Line 4: CPT/HCPCS: G8997, Mdifier: GN, CI (Prjected gal fr swallwing) Reprting n the Claim fr Visit #18 (Patient discharged frm swallwing therapy) Gals were met fr swallwing, but spken language cmprehensin and expressin have nt met therapy gals. The claim will indicate a discharge frm the plan f care fr swallwing, and the fllwing claim will reprt the secndary cnditin f spken language cmprehensin. Line 1: CPT/HCPCS 92507, Mdifier: GN Line 2: CPT/HCPCS: 92526, Mdifier: GN Line 3: CPT/HCPCS: G8998, Mdifier: GN, CI (Status f swallwing limitatin at discharge) Line 4: CPT/HCPCS: G8997, Mdifier: GN, CI (Status f swallwing prjected gal at discharge) Scenari cntinued n the next page American Speech Language Hearing Assciatin 5
Reprting n the Claim fr Visit #19 (Patient cntinues therapy fr spken language cmprehensin) Line 1: CPT/HCPCS: 92507, Mdifier: GN Line 2: CPT/HCPCS: G9159, Mdifier: GN, CK (Current status f spken language cmprehensin) Line 3: CPT/HCPCS: G9160, Mdifier: GN, CI (Prjected gal fr spken language cmprehensin) Reprting n the Claim fr Visits #20 #27 Line 1: CPT/HCPCS: 92507, Mdifier: GN N additinal utcme/gal reprting Reprting n the Claim fr Final Visit (Patient discharged frm plan f care) Patient has plateaued in therapy prgressin at FCM Level 5. The patient is discharged frm the plan f care. Line 1: CPT/HCPCS: 92507 Line 2: CPT/HCPCS: G9161, Mdifier: GN, CJ (Status f spken language cmprehensin at discharge) Line 3: CPT/HCPCS: G9160, Mdifier: GN, CI (Status f spken language cmprehensin prjected gal at discharge=gal nt met) American Speech Language Hearing Assciatin 6
Scenari 3: Patient Seen fr Evaluatin and Treatment Nt Recmmended Functinal limitatin: Vice (G cde: G9171), FCM Level 5 (Mdifier: CJ) Prjected Gal: FCM Level 5 (Mdifier: CJ) Reprting n the Claim (Required fr each time an evaluatin prcedure is billed) Line 1: CPT/HCPCS: 92524, Mdifier:GN Line 2: CPT/HCPCS: G9171, Mdifier: GN, CJ (Current status f vice limitatin) Line 3: CPT/HCPCS: G9172, Mdifier: GN, CJ (Status f prjected gal fr vice limitatin at discharge) Line 4: CPT/HCPCS: G9173, Mdifier: GN, CJ (Status f vice limitatin at discharge) American Speech Language Hearing Assciatin 7
Scenari 4: Patient Seen fr Evaluatin and Referred fr Treatment Functinal limitatin: Vice (G cde: G9171), FCM Level 3 (Mdifier: CL) Prjected Gal: FCM Level 7 (Mdifier: CH) Reprting n the Initial Claim (Prvider #1) Line 1: CPT/HCPCS: 92524, Mdifier:GN Line 2: CPT/HCPCS: G9171, Mdifier: GN, CL (Current status f vice limitatin) Line 3: CPT/HCPCS: G9172, Mdifier: GN, CH (Status f prjected gal fr vice limitatin at discharge) Line 4: CPT/HCPCS: G9173, Mdifier: GN, CL (Status f vice limitatin at discharge) Reprting n the Claim fr Treatment (Prvider #2 Cnsidered first visit) Patient is seen by treating prvider, wh determines the prjected gal shuld be FCM Level 5 (Mdifier: CJ). Line 1: CPT/HCPCS: 92507, Mdifier: GN Line 2: CPT/HCPCS: G9171, Mdifier: GN, CL (Current status f vice limitatin) Line 3: CPT/HCPCS: G9172, Mdifier: GN, CJ (Prjected gal fr vice limitatin) Scenari cntinued n the next page American Speech Language Hearing Assciatin 8
Reprting n the Claim fr Visits #2 #9 Line 1: CPT/HCPCS: 92507, Mdfier: GN N additinal utcme/gal reprting Reprting n the Claim fr Visit #10 (Reprting must ccur at least nce every 10 treatment days) Patient has cmpleted treatment at treatment visit #10 and is discharged frm plan f care. Line 1: CPT/HCPCS: 92507, Mdifier: GN Line 2: CPT/HCPCS: G9173, Mdifier: GN, CJ (Status f vice limitatin at discharge) Line 3: CPT/HCPCS: G9172, Mdifier: GN, CJ (Status f prjected vice gal at discharge=gal met) American Speech Language Hearing Assciatin 9
Scenari 5: Patient Seen fr Maintenance Therapy Maintenance therapy can be perfrmed by an SLP if skilled services are rendered. CMS requires reprting minimally every 60 days. If the maintenance therapy is s infrequent that the 10 th treatment is nt within 60 days, reprting will be required. This patient is seen nce every ther week, requiring reprting at the 60 day interval. Functinal limitatin: Mtr Speech (G cde: G8999), FCM Level 4 (Mdifier: CK) Prjected Gal: FCM Level 4 (Mdfier: CK) Reprting n the Claim at first evaluatin (Nte: Mtr speech cdes are nt in sequential rder) Line 1: CPT/HCPCS: 92507, Mdifier:GN Line 2: CPT/HCPCS: G8999, Mdifier: GN, CK (Current status f mtr speech limitatin) Line 3: CPT/HCPCS: G9186, Mdifier: GN, CK (Prjected gal f mtr speech limitatin) Reprting n the Claim (60 day interval) Line 1: CPT/HCPCS: 92507, Mdifier:GN Line 2: CPT/HCPCS: G9158, Mdifier: GN, CK (Status f mtr speech limitatin at discharge) Line 3: CPT/HCPCS: G9186, Mdifier: GN, CK (Status f prjected mtr speech gal at discharge) American Speech Language Hearing Assciatin 10