Transcript What You Need to Know Before Heading to a Medical Placement

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.
10
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
13
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.
14
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.
15
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
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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 B
Medicare 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
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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
20
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.
24
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 law
28
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.
30
ACA
Patient’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
ACA
Patient’s Bill of Rights
 Costs
 Ends lifetime limits on coverage
 Reviews premium increases
 Helps you get the most from your premium dollar
ACA
Patient’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/ModuleOne-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 diagnosis
331.0 Alzheimer’s Disease
787.20-787.29 Dysphagia
331.1 Frontotemporal dementia
332 Parkinson’s Disease
333.4 Huntington’s Chorea
340 MS
348.1 Anoxic Brain Damage
431 Intracerebral hemorrhage
435 TIA
436 CVA
507 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 1
438.82 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 Evaluations
92521 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: AAC
92605 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 speechgenerating AAC device, first hour
92608 Evaluation [92607], each additional 30 minutes
Documentation: Procedure Codes
Current Procedure Terminology (CPTs)
CPTs commonly used by SLPs: Dysphagia
92610 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 Codes
Current Procedure Terminology (CPTs)
CPTs commonly used by SLPs: Aphasia
96105 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 Codes
CPTs 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, 2425.doi:10.1044/leader.FTJ7.18072013.34)
Documentation
Glossary
 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.
Documentation
Glossary
 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 selfreport, objective data
Documentation
Glossary
 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)
Documentation
Glossary
 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
Documentation
Glossary
 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
Documentation
Glossary
 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
Documentation
Glossary
 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.
Documentation
Glossary
 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.
77
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 disciplineappropriate 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).
81
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]
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www.csha.org