Transcript 2016 CAPCSD Conference Reimbursement and Coding For

2016 CAPCSD CONFERENCE
REIMBURSEMENT AND CODING
FOR UNIVERSITY SPEECH &
HEARING CLINICS
Part I: Foundation & Structures - Don't Be Intimidated
Dee Adams Nikjeh, PhD, CCC-SLP
Paul Pessis, AuD
Tim Nanof, MSW
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Speaker Disclosures
• Financial
Each speaker received complimentary registration
for this meeting and air fare
• Non-Financial
Nikjeh: Co-chair ASHA Health Care Economics
Committee, Alternate co-chair RUC HCPAC
• Pessis: Reimbursement and practice management
consultant for healthcare providers
• Nanof: Ex-officio of ASHA’s Health Care
Economics Committee
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Agenda Part I: Foundation and Structure
• Key Health Care Coding Systems
• International Classification of Diseases -10th Rev
• HCPCS Level I - Current Procedure Terminology
• Procedure to Payment
• 2016 Medicare Physician Fee Schedule for SLP & AUD
• HCPCS Level II – Equipment, Supplies, Devices
• Rules and Tools for Coding Efficiency
• National Correct Coding Initiative Edits
• Speech-Language Pathology
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Timed versus Untimed Codes
Medically Unlikely Edits
Multiple Procedure Payment Reduction
Therapy Cap
• Audiology
• Physician Referral
• Medical Necessity
• Practice Coding Scenarios for Audiology and SLP
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KEY HEALTH CARE CODING
SYSTEMS
International Classification of Disease, 10th Rev,
Clinical Modification
Healthcare Common Procedure Coding System –
Level I and Level II
Purpose of Coding Systems
• Provide common language among providers, third-
party payers, and administrators
• Standardize descriptions of procedures, names of
diagnoses, and names of items/supplies
• Provide data for government to evaluate utilization
patterns and appropriateness of health care costs
• Provide data for health-related research
HIPAA mandated code sets: CPT, ICD-10, HCPCS
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Healthcare Common Procedure Coding
System (HCPCS)
• HCPCS Level I
• a.k.a. Current Procedural Terminology (CPT)
• Represent what we DO (procedures & services) with
the client/patient
• Owned by American Medical Association
• HCPCS Level II
• Based on the American Medical Association's Current
Procedural Terminology (CPT)
• Codes used to report supplies, equipment, and devices
International Classification of Diseases, 10th Revision,
Clinical Modification
• Diagnostic codes that describe the REASON
we are evaluating or treating the client/patient
• ICD-10-CM effective October 2015
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INTERNATIONAL
CLASSIFICATION OF DISEASE,
10TH REVISION, CLINICAL
MODIFICATION
October 1, 2015
ICD-10-CM
• ICD-10 includes approx 160,000
• ICD-10-CM diagnosis codes for all settings
• > 68,000 codes in Clinical Modification
• ICD-10-PCS procedure codes for hospital inpatients
• 21 Chapters based on body systems (e.g. nervous,
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circulatory, respiratory, digestive)
3-7 alphanumeric characters instead of current 3-5
digits
Owned by the World Health Organization (WHO)
Required for everyone covered by the Health
Insurance Portability Accountability Act (HIPAA)
Does NOT affect CPT coding
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ICD Coding Principle
• Highest degree of medical certainty or specificity
• Carry out to the 7th place (Letters and Numbers) which is
the 4th or 5th number when possible.
• SLP example
• General = R41.8 Other symptoms and signs involving
cognitive functions and awareness
• More specific = R41.844 Frontal lobe and executive function
deficit
• Audiology example
• General = H90.8 Mixed conductive and sensorineural hearing
loss, unspecified sensorineural hearing loss, bilateral
• More Specific = H90.41 Sensorineural hearing loss, unilateral
right ear with unrestricted hearing on the contralateral side
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ICD Coding Principle
• When results of diagnostic testing are
NORMAL, code signs or symptoms to report
the reason for test/procedure and explain
normal result in report
• There is NO ICD code for “normal”
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Official Instructions - How to Code When
Results are Normal
• For outpatient services, ICD-10-CM guidelines state, “Do not
code diagnoses documented as 'probable,' 'suspected,'
'questionable,' 'rule out,' or 'working diagnosis' or other
similar terms indicating uncertainty. Rather, code the
condition(s) to the highest degree of certainty for that
encounter/visit, such as symptoms, signs, abnormal test results,
or other reason for the visit.”
• For inpatient services (including short-term, acute, and longterm care), ICD-10-CM advises "If the diagnosis documented at
the time of discharge is qualified as 'probable,' 'suspected,' 'likely,'
'questionable,' 'possible,' or 'still to be ruled out' or other similar
terms indicating uncertainty, code the condition as if it existed
or was established.”
ICD-10-CM Official Guidelines for Coding and Reporting
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ICD Coding Principle
• Code “other” or “other specified” when information in medical
record provides detail for which a specific code does not
exist; usually code ends with a 4th digit “8” or 5th digit “9”
• H91.8X- Other specified hearing loss
• F80.89 Other developmental disorders of speech and language
• Code “unspecified” codes when information in medical record
is insufficient to assign a more specific code; usually code
ends with a 4th digit “9” or 5th digit “0”
• F80.9 Developmental disorder of speech and language, unspecified
• R49.9 Unspecified voice and resonance disorder
• R42 Dizziness and giddiness (replaced CPT) 780.4 - excludes
vertiginous syndromes, but is used for light-headedness or vertigo
not otherwise specified
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ICD Coding Principle
•ICD code (reason) and CPT code (procedure)
should correspond for encounter.
•SLP Example
•ICD R13.11 Dysphagia, oral phase
•CPT 92610 Clinical Swallow Evaluation
•Audiology Example
•ICD H90.11 Conductive hearing loss, unilateral, right ear, with
unrestricted hearing on the contralateral side
•CPT 92557 Comprehensive audiometry threshold
evaluation and speech recognition (92553
and 92556 combined)
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ICD Coding Principle
• Primary diagnosis - condition (disease, symptom, injury) chiefly
responsible for visit or reason for encounter
• Secondary diagnoses - co-existing conditions or symptoms, or
condition found after study
• Primary R49.21 Hypernasality
• Secondary Q37.4 Cleft Palate
• Exceptions - Instructions for “code first,” “use additional
code,” or “in diseases classified elsewhere”
• I69.391 Dysphagia following cerebral infarction “use additional code
to identify the type of dysphagia, if known”
• R13.1 Dysphagia “Code first, if applicable, dysphagia following
cerebral vascular disease”
• R47.82 Fluency disorder in conditions classified elsewhere; “Code first
underlying disease or condition, such as Parkinsons’s disease (G20)”
• Coding preferences may also be specific to your work setting or
payer
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ICD Coding Principle - NEW
Excludes1
• Indicates that codes should never be listed
together because the two conditions cannot occur
together
SLP Example:
F80.1 Expressive language disorder, developmental
dysphasia or aphasia, expressive type
Excludes1 mixed receptive-expressive
language disorder (F80.2);
dysphasia and aphasia NOS (R47.-)
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ICD Coding Principle
New twist for SLPs…
• Due to an Excludes1 note, the R47 family (dysarthria,
speech disturbance, etc.) cannot be used in conjunction
with the code for Autism (F84.0)​
• ASHA is looking into options to resolve the issue
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• In the meantime, use F80.0 (developmental
phonological disorder) with the autism diagnosis
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ICD Coding Principle - NEW
Excludes 2
• Indicates codes that may be listed together because
the conditions may occur together, even if they are
unrelated
Example:
G40.80 Acquired aphasia with epilepsy [Landau-Kleffner]
Excludes2 selective mutism (F94.0)
intellectual disabilities (F70-F79)
pervasive developmental disorders (F84.-)
NEW ICD-10 Chapter 20 External Causes
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ASHA Tools for ICD-10-CM
• Lists for AUD and SLP ICD-10 codes on the
ASHA website
• www.asha.org/uploadedFiles/ICD-10-Codes-Audiology.pdf
• www.asha.org/uploadedFiles/ICD-10-Codes-SLP.pdf
• Online Mapping Tools for ICD-9 to ICD-10
codes: www.asha.org/icdmapping.aspx
• 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
• Products are free and tailored for speech-
language pathology and audiology
ICD-10-CM
Audiology
Appropriate codes found in:
• Alphabetic Index - alphabetical list by disease
OR
• Tabular List – numeric list of codes divided into 21 chapters according to
body system or nature of injury or
disease
• Most Audiology codes are located within the Chapter 8:
Ear and Mastoid Process
Diseases of the
ICD-10-CM Audiology
Laterality and Placeholder
• Laterality:
• The final digit indicates laterality: 1 is for right; 2 for left; 3 for
bilateral; 0 or 9 for unspecified
• Placeholder character
• “X”– Some codes have a placeholder in the 6th digit to allow for
future expansion
ICD-10 Coding Options
H90 Conductive and sensorineural hearing loss
• H90.0 Conductive hearing loss, bilateral
• H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted
hearing on the contralateral side
• H90.12 Conductive hearing loss, unilateral, left ear, with
unrestricted
hearing on the contralateral side
• H90.3 Sensorineural hearing loss, bilateral
• H90.41 Sensorineural hearing loss, unilateral, right ear, with unrestricted
hearing on the contralateral side
• H90.42 Sensorineural hearing loss, unilateral, left ear, with unrestricted
hearing on the contralateral side
Additional Options
• H90.6 Mixed conductive and sensorineural hearing loss,
bilateral
• H90.71 Mixed conductive and sensorineural hearing loss, unilateral, right
ear, with unrestricted hearing on the contralateral side
• H90.72 Mixed conductive and sensorineural hearing loss, unilateral, left ear,
with unrestricted hearing on the contralateral side
• H90.8 Mixed conductive and sensorineural hearing loss,
unspecified
It’s Not All Bad:
Being Specific…
• H91.21 Sudden idiopathic hearing loss, right ear
• H83.3X3 Noise effects on inner ear, bilateral
• H93.11 Tinnitus, right ear
• H93.231 Hyperacusis, right ear
• H83.02 Labyrinthitis, left ear
• H91.03 Ototoxic hearing loss, bilateral
• H93.243 TTS, bilateral
Third party payers want specificity which needs to
be supported with detailed chart documentation
Don’t Worry, Be Happy!
• Quiz time: What constitutes a proper diagnosis? Hint: three
things
• History
• Symptoms
• Findings
• Currently, there are no codes to represent a different type of
hearing loss for EACH ear: (i.e., conductive of the right and
sensorineural of the left)
American Academy of Audiology
Tools for ICD-10-CM
Available Resources Include:
• Editable superbill template for CPT, ICD-10, CPT Modifiers, and PQRS
Measurement reporting guidelines
• Comprehensive listing of audiology related ICD-10 codes with descriptor
• Important links and tools
http://www.audiology.org/practice_management/coding/internationalclassification-diseases-10th-edition
2016 CURRENT PROCEDURAL
TERMINOLOGY
Procedure to Payment
2016 Medicare Physician Fee Schedule for SLP & Aud
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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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AMA Criteria for CPT Codes
• Unique procedure that is not covered by other established
codes
• Procedure widely used within U.S.
• Not investigational
• Supported by substantial peer reviewed literature in
published in US journals
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Relative Value Unit (RVU)
• Every CPT procedure or service has a resource-
based relative value
• Payment for services are determined by the
resource costs needed to provide them
• 3 Components of a relative value unit
• Professional Work
• Practice Expense
• Malpractice Insurance
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Relative Value Unit- 3 Components
• *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
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From Relative Value to Dollar Value
• Relative Value Units (RVUs) are assigned thru a
rigorous procedure developed by the AMA
• All medical procedures are ranked on the same
relative value scale
• AMA recommendations for RVUs sent to Centers for
Medicare and Medicaid (CMS)
• Accepted, rejected, or adjusted
• Ranked
• RVU X Monetary Conversion Factor = Medicare
Payment per Procedure
• Establishes the Medicare Physician Fee Schedule
• Payment adjusted for geographic location
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CPT & RUC Process
AAA and/or ASHA
Complete Request Form
Collect Data
Write Vignettes
Collaborate Related Orgs
CPT HCPAC
Advisors
CPT Editorial Panel
Defend
Negotiate
Rationalize
RUC HCPAC
Advisors
Practice Expense
Subcommittee
CPT Code Book
Medicare Fee Schedule
Approximately 3 Years
RUC – Relative Value Update Com.
Recommend a Relative Value
Defend Professional Work Value
Professional Liability/Insurance
CMS
Accept, Reject, Adjust
ASHA Advocacy
Reimbursement Assigned
Healthcare Professional Advisory Committee Review
Board
• Non-Physician Representation
• Members – Audiologists, Speech-Language Pathologists, Chiropractors,
Dieticians, Nurses, Occupational Therapists, Optometrists, Physical Therapists,
Physician Assistants, Podiatrists, Psychologists, Social Workers
• CPT HCPAC: reviews applications for new or revised CPT
codes for non-
physician specialties
• RUC HCPAC: reviews recommendations for the RVU for physician work and
practice expense for non-physician specialties
Conversion Factor
• 2016 Conversion Factor = $35.8279 (as compared to
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$35.9335 from 2015)
CF remains stable with annual payment increase of
0.5% thru 2019
Payment frozen from 2020 to 2025
After 2025 payment adjustments based on
participation in alternative payment models and quality
measures
More on that in Part 2
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Medicare Physician Fee Schedule
(MPFS)
• All references to MPFS include the 80% that
Medicare pays and the 20% patient coinsurance
• Many private insurers and Medicaid programs model
their own payments on Medicare’s
• MPFS ends up largely determining physician
incomes…and ours too…all Medicare Providers
• MPFS appears in Final Rule usually around Nov 1
for following year
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2016 Medicare Physician Fee Schedule
ASHA – Speech-Language Pathology
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Common (not all) SLP Evaluation CPT Codes
• 92521 Evaluation of speech fluency
• 92522 Evaluation of speech sound production (e.g., articulation,
• 92523
• 92524
• 92607
• 92610
• 96105
phonological process, apraxia, dysarthria
Evaluation of speech sound production with evaluation of
language comprehension and expression
Behavioral and qualitative analysis of voice and resonance
Evaluation for prescription of speech-generating AAC
device, face to face with patient, first hour
Evaluation of oral and pharyngeal swallowing function
Assessment of aphasia with interpretation and report, per
hour
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Common (not all) SLP Treatment CPT Codes
• 92507 Treatment of speech, language, voice,
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communication, and/or auditory processing disorder
92508 Group, 2 or more individuals
92526 Treatment of swallowing dysfunction and/or oral
function for feeding
92609 Therapeutic services for use of speech-generating
device, including programming and modification
97532 Development of cognitive skills to improve attention,
memory, problem solving (includes compensatory training),
direct (one-on-one) patient contact by provider, each
15mins
MPFS Audiology Codes
CODE
92557
92570
92537
92538
92540
92585
92587
92588
2015 Fee
$37.73
$32.34
N/A
N/A
$103.13
$109.96
$21.56
$33.42
2016 Fee
$37.98
$32.60
$40.84
$20.78
$102.83
$136.86
$21.86
$33.32
1985 – Fee-For-Service - $88.00 for CPT 92557
Common Audiology CPT Codes
• 92557 – Comprehensive audiometry, bilateral (air, bone, speech)
• 92567 - Tympanometry
• 92568 – Acoustic reflexes
• 92369 – Acoustic reflex decay
• 92550 – Tympanometry and reflexes
• 92570 – Tympanometry reflexes, and reflex decay
• 92540 – Bundled vestibular (4 categories)
• 92537 - Caloric vestibular test with recording, bilateral; bithermal (4)
• 92538 - Caloric testing with recording, bilateral; monothermal (2)
• 92587 – OAE; limited 3-6 frequencies (interpretation and report)
• 92588 – OAE; Comprehensive min 12 frequencies (Interp and report)
• 92585 – Auditory evoked potentials; comprehensive
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Rules and Tools for Coding
Efficiency
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Coding Clarifications – Edit Systems
• National Correct Coding Initiative (CCI) – any Part B
services not rendered in a hospital
• Outpatient Code Editor (OCE) – outpatient hospital
services, very similar to CCI
• Automated edit systems used by CMS to control
specific CPT code pairs that can be reported on the
same day for the same patient
• CCI is updated quarterly and OCE follows one
quarter later
• Since 2010, CCI applies to Medicaid per federal law
Coding Clarification
Modifiers SLPs need to know
• -59 Distinct and Separate Procedural Service
• Only modifier used with NCCI edits
• For two procedures not ordinarily performed on same day by 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)
• 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)
• -52 Indicates Shortened Procedure
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ASHA CCI Edit Page for SLP Codes
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www.asha.org/practice/reimbursement/
coding/CCI_edits_SLP.htm
Coding Clarification
Modifiers Audiologists Need to Know
• 22 – Increased procedural services
• 26 – Professional component
• TC- Technical component
• 52 – Reduced services
• 53 – Discontinued procedure
• GA – Mandatory use of ABN
• GY – Statutorily excluded service
• Ex., Denial for secondary insurance
CCI Edits for Audiology Codes
• 69210 (cerumen management) cannot be billed on the same date of service
with audiometric/vestibular tests
• If they are billed together, CMS will only pay for audiometric/vestibular!
• Can bill G0268 (Removal of impacted cerumen, one or both ears by physician on
same date of service as audiologic function testing) for cerumen with 92557, for
example
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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
• 96125
1
1
1
2
• 96105
3
• 92526
• 92610
speech tx
dysphagia tx
clinical eval of swallowing
standardized cognitive performance testing
per hour
aphasia assessment per hour
Timed versus Untimed Procedure Codes
Applies to Out-patient (Part B) Services
• Most CPT codes reported by SLPs are NOT timed-
codes
• Example: CPT 92507 (speech therapy) is NOT a timed-
code, bill per visit, not unit of time
• Most SLP codes represent a typical visit length
• Determined by membership survey during the development
of the code
• Most CPT codes are billed as ONE visit
•
•
Note: some state Medicaid agencies allow timed billing and
multiple units
Note: Does not apply to Part A Prospective Payment Systems
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Timed Versus Untimed Codes
Specific SLP Timed Procedures
• 92607: Evaluation for prescription of speech-generating
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device, first hour
92608: each additional 30 mins
92626: Evaluation of auditory rehabilitation status, first
hour
92627: each additional 15 minutes
96105: Assessment of aphasia, per hour
96125: Standardized cognitive performance testing, per
hour
97532: Development of cognitive skills, each 15 mins
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Timed Versus Untimed SLP Codes
Time Requirements
• Time documented must correspond to number of units
billed on the claim
• Time spent must exceed halfway point dictated by the
code:
• 1-hour unit ≥ 31 minutes
• ½ hour unit ≥ 16 minutes
• 15-minute unit ≥ 8 minutes
• Subsequent timed-units may not be counted until the
full value (first code) plus ½ of the value is exceeded
(second code)
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Timed Versus Untimed SLP Codes
Time Requirements - Example
• An aphasia assessment took 60 minutes with the patient
and scoring, interpretation and documentation took an
additional 45 minutes.
• CPT 96105 = 1 hour per each unit billed, max of 3
• To bill a second unit of 96105, 91 minutes must be
documented on evaluation and report; (first hour + ½ of
second hour + 1 min)
• In this case, 105 minutes are documented. It is appropriate
to bill 2 units of 96105.
Multiple Procedure Payment Reduction
Policy (MPPR)
• Applies to any and all therapy disciplines
performed on the same day
• Does NOT include audiology at this time
• Therapy service or unit with highest practice expense
(PE) value receives full reimbursement
• For additional services provided on same day, CMS
reduces PE by 50% (but not professional work or
malpractice expense components)
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Multiple Procedure Payment Reduction
• Primarily affect professions that bill multiple procedures,
or bill a timed procedure more than once per visit
• Ex: If 92507 and 92526 are provided on same day,
payment of PE for 92507 would be reduced by 50% since
PE is less for speech/lang tx than dysphagia tx
• MPPR is a per-day policy that applies across disciplines
and settings
• If SLP and Physical Therapy both provide treatment to the
same patient on the same day, the MPPR applies to all
codes billed that day regardless of discipline
• Code with greatest PE gets full payment and others have PE
reduced
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SLP/PT Therapy Fee Cap
• Balanced Budget Act of 1997 Congress placed an annual
cap on rehab services under Medicare; Began 1999
• 2016 combined PT and SLP cap = $1,960 per beneficiary
per year; OT – individual cap $1,960
• Two-tiered exceptions process
• Automatic exceptions
• Manual medical review exceptions
• Automatic exceptions - Use KX modifier, if applicable, for
those who have exceeded the cap
• Therapy cap in effect until December 31, 2017
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Resources for Medicare Fee Schedule, Edits, and
Modifiers
• http://www.audiology.org/advocacy/final-rule-changes-2016•
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•
medicare-physician-fee-schedule
www.asha.org/practice/reimbursement/medicare/feeschedule/
www.asha.org/practice/reimbursement/coding/CCI_edits_SLP.h
tl
www.asha.org/practice/reimbursement/coding/CCI_edits_Aud.h
tl
www.asha.org/Practice/reimbursement/coding/MedicallyUnlikely-Edits-SLP/
www.asha.org/Practice/reimbursement/coding/MedicallyUnlikely-Edits-Audiology/
http://www.audiology.org/practice_management/coding/national
-correct-coding-initiative-cci-edits-audiology-procedures
SLP CODING SCENARIOS
Let’s Practice Coding!
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Case Scenario CPT Coding Question
• The patient had a cerebral infarct and presents with aphasia and
dysarthria. Which evaluation procedure code(s) is/are your best
choices?
A. CPT 92523 (speech sound production with receptive & expressive
language)
B. CPT 96105 (aphasia assessment per hour) and CPT 92522 (speech sound
production)
C. CPT 92523 and CPT 92522
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Case Scenario CPT Coding Answer
Best choice of evaluations for CVA and dysarthria: Choice B
• CPT 92522 (speech sound production) and CPT 96105 (aphasia
assessment per hour)
• Use -59 modifier on the second procedure
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Case Scenario ICD-10 Coding Question
• The patient had a cerebral infarct and presents with aphasia and
dysarthria. Which diagnostic code (s) (ICD-10) is/are your best
choice?
A. I69.320 Aphasia following cerebral infarction
I69.322 Dysarthria following cerebral infarction
B. I69.32 Speech and language deficits following cerebral infarction
C. R47.01 Aphasia
R47.1 Dysarthria and anarthria
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Case Scenario ICD-10 Coding Answer
• Answer is : A
• I69.320 Aphasia following cerebral infarction
• I69.322 Dysarthria following cerebral infarction
• I69.32 is not the most specific code choice
• R47 codes have an “Excludes 1” excluding aphasia and dysarthria
following cerebrovascular disease I69.
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Case Scenario CPT Coding Question
• Ms. Jones has Parkinson’s disease and presents with
impairments of expressive/receptive language, motor
speech and voice. Which evaluation procedures are
appropriate?
A: CPT 92523 (speech sound production with
expressive/receptive language) and CPT 92524
(behavioral and qualitative analysis of voice and
resonance)
B: CPT 92523 and CPT 92522 (speech sound production)
C: CPT 92522 and CPT 92524
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Case Scenario CPT Coding Answer
• Answer is A
• CPT 92523 (speech sound production with expressive/receptive
language) and CPT 92524 (behavioral and qualitative analysis of
voice and resonance)
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Case Scenario
Billing Multiple Units Question
• The evaluation for cognitive status using standardized
measures took 50 mins with the patient. The interpretation
and report writing took 30 mins and was documented in
the medical record.
• How many units of CPT 96125 (1 hr/ea unit) may be
billed for this evaluation?
A: one unit
B: two units
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Case Scenario
Billing Multiple Units Answer
• The Answer is: A
• CPT 96125 is a timed code and may be billed in 1-hour
units of time for a maximum of two units.
• In this case 80 mins are documented in the record. It is
appropriate to bill only one unit of CPT 96125.
• To bill a second unit of 96125, 91 minutes (first hour + ½
of second hour + 1 min) must be documented for the
evaluation, interpretation, and report.
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Case Scenario ICD-10 Question
• A child with diagnosis of autism is referred for a speech-
language evaluation. Assessment measurements indicate
that the child has a language deficit. How should the SLP
code the diagnosis?
A: F84.0 Autistic disorder
B: F80.2 Mixed receptive-expressive language disorder
C: R48.8 Other symbolic dysfunctions (primary diagnosis)
F84.0 Autistic disorder (secondary diagnosis)
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Case Scenario ICD-10 Answer
• The answer is… C….Maybe
• R48.8 Other symbolic dysfunctions
F84.0 Autistic disorder
• Use symbolic dysfunction rather than F80.2 (Mixed receptiveexpressive language disorder) since there is an underlying disorder
contributing to the language problems. F80.2 is in the
“developmental” section.
• Under question is the order of these two codes; that is, Primary
versus Secondary
• ASHA seeking guidance on this issue
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Case Scenario ICD10 Question
• A 5-year old child was referred to SLP by pediatrician for evaluation of
unintelligible speech. ICD-10 code from the physician was F80.0. Evaluation
of speech sound production was completed and child’s articulation was within
normal limits. What is the correct ICD-10 code for the evaluation?
A: R 47.1
Dysarthria
B: O.0X0X Normal
C: F80.0
Phonological disorder
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Case Scenario ICD-10 Answer
• The answer is C – Phonological Disorder
• There in NO CODE to indicate normal
• Explain results in the documentation
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Case Scenario ICD Coding Question
• The patient has been diagnosed with
Alzheimer’s disease. SLP treatment
focuses on improvement of communication.
What ICD-10 codes do I use?
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Case Scenario ICD Coding Answer
• ICD-10 codes for cognitive-communication
treatment for patients with Alzheimer’s disease:
 R48.8 Other symbolic dysfunctions
 G30.0 – G30.9 series for Alzheimer's disease
(early onset, late onset, etc)

G30 requires additional codes to identify dementia with or
without behavioral disturbance (F02.8X series)
Case Scenario – CCI Edits Question
• SLP performs speech/language evaluation and
treatment on the same date of service.
• What are the CPT codes to bill?
A: None, cannot bill for both of these
procedures on the same day
B: CPT 92523 and 92507
C: Only CPT 92523
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Case Scenario NCCI Edits
Answer
• The answer is: B
• CPT Code(s): 92523 and 92507
• No modifier needed; no edit indicating an evaluation and
treatment cannot be done on the same date
• Would need to have Plan of Care (POC) by next day if Medicare
• If private insurance, they might want to approve POC before
authorizing treatment. In that case, do not schedule therapy on
the same date
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Case Scenario CPT Coding Question
• I am treating an 11-year old who has been diagnosed
with ADHD and is struggling in the classroom because
of poor attention and memory skills. I work directly on
memory enhancing techniques (e.g., chunking) and
compensatory strategies.
• Can I bill CPT 97532 (cognitive treatment per 15
mins)?
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Case Scenario CPT Coding
Answer
• It seems that your treatment matches the procedure
code description.
• It will depend on your payer:
• If CPT 97532 is not covered, then CPT 92507
(speech and language therapy) would be an
appropriate choice
• You may NOT use both on the same date
• CPT 97532 is a timed 15-min procedure
• CPT 92507 is an untimed code
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Case Scenario CPT Coding Question
• A 4-year old child was referred for a speech and
language evaluation. I spent two hours on the first
visit and completed the evaluation on the second visit.
In addition, I spent one hour writing the report.
• May I code and bill CPT 92523 (Evaluation of speech-
sound production with evaluation of language) for
each visit?
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Case Scenario CPT Coding
Answer
• No, remember that CPT 92523 is an untimed procedure code.
• You may only bill one time for the initial evaluation CPT 92523.
• Try to complete enough of the evaluation on the initial visit so that you may
determine a plan of care
• You may complete additional assessment as needed on the second visit and
bill as part of the treatment CPT 92507.
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RESOURCES
• ASHA Reimbursement and Advocacy Modules for SLPs and
Audiologists
• FREE!
• 9 modules, 10 to 20mins each
• Designed for graduate students but used by all
• In 2014, 4,000 hits per quarter
• http://www.asha.org/Practice/reimbursement/modules/
• https://www.youtube.com/playlist?list=PL8XYIFygdg6XL5_Al6jqil3Y1QWf
pKNzQ
AAA Resources:
• http://www.audiology.org/practice-management/coding
• E-Audiology Coding and Reimbursement Series:
https://www.eaudiology.org/coding-and-reimbursement
• http://www.audiology.org/about-us/volunteeropportunities/committees-task-forces/coding-reimbursementcommittee
AUDIOLOGY CODING SCENARIOS
Let’s Practice Coding!
Let’s Practice
A patient presents with impacted cerumen and you want to remove it. It is
within your state scope of practice to remove cerumen, but Medicare considers
it a treatment code, and audiologists are credentialed to perform diagnostic
services.
Conundrum:
1. The patient insists that secondary insurance will pay for the cerumen
removal, but you know it is illegal to bill Medicare for a service that is not
covered. What do you do?
Ans: Bill Medicare using 69210 and affix the “GY” modifier. On line 19 of the
CMS 1500 form add “need denial for secondary insurance”
Pondering the ABN
Do you need to have the patient sign an ABN?
ANS: Under Medicare, an audiologist is statutorily prohibited to bill Medicare
for cerumen management, therefore, it is NOT necessary to have the patient
sign the ABN. The patient, however, can be billed as an out-of-pocket expense
and the Medicare Physician Fee Schedule does not apply.
Bundled Codes
92557, comprehensive audiometry threshold evaluation and speech recognition
(92553, air and bone, and 92556, speech testing combined) is listed in the
MPFS as $37.98. If one was to bill both 92553 and 92556 individually, the
Medicare payment doubles?
Why not bill 92553 and 92556 instead of 92557?
ANS: It is illegal to bill for the components of a bundled code if all components
of the bundled code are being billed. The rationale is that the RVU is less for
the bundled because redundant services occur with a bundled code
Free
FACT: Medicare does not allow a Medicare patient to be billed more than a nonMedicare patient.
Scenario: Your clinic is having a marketing campaign which invites Medicare
beneficiaries to come in to your clinic and have a free hearing test – 92557
Question: Is this a good marketing strategy?
ANS:
1. Can no longer bill MC patients for this equivalent service (could do a
screening)
2. Medicare can’t be billed due to no physician referral and a lack of medical
necessity
ICD-10
A patient presents with a left conductive hearing loss and a right sensorineural
hearing loss, but there isn’t a code to represent this presentation. What do you
do?
ANS: Code
A. H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted
hearing on the contralateral side
B. H90.42 SNHL, unilateral, left ear, with unrestricted hearing on the
contralateral side
C. Code both A and B
D. H90.2 Conductive hearing loss, unspecified
E. H90.5 Sensorineural hearing loss, unspecified
F. Both D and E
Best Practices
Your clinic believes that a patient should have an annual hearing test. As a
courtesy to your patients, you send them a reminder. This is a good practice:
A) If you have the patient obtain a physician referral before coming to your
clinic
B) For established patients because you already have a physician referral from
the initial visit
C) This would be considered soliciting a referral and is an illegal Medicare
practice
D) If you bill the patient, not Medicare
ANS: C and D
CPT Modifiers
A patient is scheduled for 92557 which is described as a binaural procedure.
Your patient has a recent hearing test documenting normal hearing for the right
ear, but a conductive loss in the left. You only perform a left ear test.
How is this billed?
A) Bill 92557
B) Bill 92557 with the 52 modifier
C) Bill 92557 with the 53 modifier
D) Bill 92553 and 92556
E) Either B or D
ANS: B
2016 CAPCSD Presentation Part I Questions?
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