Many people see January 1 as an opportune time to set goals and expand their knowledge or skill sets. For some, that could mean learning a new language; for others, it could be reading more novels throughout the year. For speech-language pathologists, one New Year’s resolution might be brushing up on billing best practices. After all, with Medicare’s recent cut to reimbursement for therapy services, making every claim count will be more important than ever in the new year. With that in mind, here are five things every SLP should know about billing for outpatient services:
1. SLP and PT services are combined under the same targeted review threshold.
Since 1998, rehab therapy services have been subject to a specific allotted amount for each reporting year under Medicare Part B. For 2021, the allotted amount for speech-language pathology services is $2,110. But—and this is a big “but”—that amount also includes any physical therapy services a Part B beneficiary receives throughout the year. For any claims that exceed this threshold, providers must affix the KX modifier to denote the medical necessity of continued treatment and thus, receive reimbursement for additional services.
Because PT and SLP services count toward the same threshold amount, it’s absolutely critical that SLPs inquire about any physical therapy services a Medicare patient has received during the plan year before submitting claims for any SLP services. You can contact your MAC to check on a patient’s progress toward the cap, but if the PT services were recent, there’s a chance some of the claims haven’t been processed—in which case you may want to contact the PT clinic to verify claim totals.
Furthermore, there is a second threshold at $3,000. Any claims that exceed this amount may be subject to a targeted manual medical review. (However, merely exceeding the threshold does not automatically trigger such review, and you should not avoid going above $3,000 if continued treatment is medically necessary.)
2. Medicare will not pay for student-led services.
According to Chapter 15 the Medicare Benefit Policy Manual, “only the services of the therapist can be billed and paid under Medicare Part B. The services performed by a student are not reimbursed even if provided under ‘line of sight’ supervision of the therapist.”
That said, student participation in a service does not automatically make it non-reimbursable. Section 230.B goes on to state that students may assist in services rendered by a licensed SLP or deliver services under the direct guidance and supervision of the licensed provider. This guidance also applies to group therapy services.
The rules are a little different for clinical fellows. According to ASHA, “This student policy does not apply to clinical fellows practicing in States that grant clinical fellows temporary or provisional licensure…However, in States without such licensure, Medicare treats clinical fellows as graduate students requiring ‘in the room’ supervision.”
3. Medicare does not require SLPs to obtain a physician referral or order before providing services.
Under Medicare, a speech-language pathologist may evaluate a patient, establish a plan of care, and begin treating—all without obtaining a physician referral. However, as ASHA explains in this Medicare FAQ guide for SLPs, the plan of care “must be certified by the patient’s physician within 30 days. For outpatient services, the plan of care must be recertified by the physician every 90 days from the initiation of treatment or when there is a significant modification to the plan.” Additionally, either the physician or SLP can make small modifications to the plan of care, but the SLP may not significantly alter it without receiving recertification from the physician.
4. SLPs may use 97000 series CPT codes—if appropriate.
If you’re familiar with the 97000 series of CPT codes, then you know physical therapists typically use them to bill for PT services. But, you may not know that SLPs can use these codes as well. Under Medicare, SLPs may use CPT codes 97129 (cognitive function intervention, initial 15 minutes) and 97130 (cognitive function intervention, each additional 15 minutes) when treating cognitive disorders. However, as ASHA notes in this coding FAQ, “either code 92507 or 91729/97130 could be used, but not both on the same day by the same provider.”
Keep in mind that because 97000 series codes are typically reserved for physical medicine, some SLPs may struggle to receive reimbursement for them. It’s also important to note that using codes from both the 92000 and 97000 series on the same claim could result in unbundling, which Medicare does not allow. Specifically, the National Correct Coding Initiative (NCCI) manual states that “speech language pathologists should not report CPT codes 97110, 97112, 97150, 97530, or 97129 as unbundled services included in the services coded as 92507, 92508, or 92526.”
However, cases wherein use of codes from both series can be justified (e.g., co-treatment involving both a PT and an SLP on the same date of service), providers may be able to bill for both code types by using modifier 59. You can verify whether modifier 59 is appropriate for a particular set of codes by consulting the edit pair chart found in this modifier 59 blog.
5. Medicare does not reimburse assistant-led speech services.
As ASHA states in this certification guide, “Under Medicare, services provided by speech-language pathology assistants [SLPA] are not considered medically necessary and therefore are not reimbursable.” This rule can catch providers off guard, as it diverges from Medicare’s policy for physical therapist assistants (PTAs) and occupational therapy assistants (OTAs). As for commercial payers, providers will need to check with each entity individually to confirm its policy on SLPA service reimbursement. That said, many private payers align their reimbursement policies with Medicare’s.
Other Important Considerations
Documenting properly—and defensibly—is a super important facet of an SLP’s responsibilities. As with billing, each payer may have its own documentation requirements, so it’s crucial to confirm this information whenever you become credentialed with a new payer. Not sure your documentation is up to snuff? WebPT’s Courtney Lefferts outlines the following guidelines for documenting defensibly:
- “Describe the patient’s medical history and diagnosis; then, use your findings to communicate the necessity of your care.
- Observe and document your patient’s responses to treatment.
- Use action words to describe your treatment and the patient’s goals.
- Avoid using abbreviations.
- Produce legible documentation. (Hint: Document patient care electronically using an EMR.) If your payers can’t decipher your notes, your claims might be denied.
- Incorporate standardized tests and measurements.”
Furthermore, it’s important to document medical necessity—especially where Medicare is concerned—in order to receive reimbursement and justify any billing disputes.
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Many SLPs and first-time practice owners run into some confusion when establishing fees for their services. The Medicare fee schedule for your region is a good place to start. Of course, Medicare’s fee schedule may not reflect the current market rates, so we also recommend seeking guidance from your local peers and your state-level speech therapy organization. However, if you confer with other practices on their fee schedule amounts, ASHA warns that this “may be construed as price-fixing” and that “setting prices in collusion with colleagues is illegal.”
Procedure and Diagnostic Code Resources
Here are some resources for researching diagnostic and service codes for speech-language pathology (as well as obtaining pricing information):
- Medicare Fee Schedule
- ASHA’s coding web page
- American Medical Association (AMA)
- ASHA’s ICD-10 website
- National Center for Health Statistics
Place of Service Codes
As ASHA explains in this guide, “Place of service codes are used on claims to specify the entity where service(s) were rendered. Check with individual payers (e.g., Medicare, Medicaid, private health plans) for policies regarding these codes.” Typically, outpatient private practices are considered an “office” location.
To see a full list of these codes, check out this resource from the Centers for Medicare and Medicaid Services (CMS).
So, there you have it: five billing best practices for speech-language pathologists—and a few extra tips for good measure. Got any burning questions? Drop them in the comment section below!