Speech-language pathologists are often called upon to provide services to a wide range of patients in a variety of venues. This includes working with schools and other educational institutions as well as working with patients in a clinical setting or in some cases from the comfort of their own homes. In recent years remote services have started becoming popular for speech-language pathologists who work with patients in remote, rural locations. Where travel is prohibitive.
This can create challenges in the realms of coding and medical billing practices. Especially if you are offering your services in a variety of settings, or you are a solo practitioner trying to handle your own coding and medical billing needs.
At first glance, the process seems simple. You provide industry-best speech therapy services to the patient, you write up a bill with important codes set into the claim. Then you send it to the patient’s insurance company or the oversight of the public health institution responsible for paying the claim. The claim is processed and you are reimbursed according to your previously negotiated rate.
Unfortunately, the coding and medical billing process can be a lot more complicated than that. It is often mired by things like the need for prior authorizations, a policy’s visit limits, coding errors, and accounting for deductibles, copays, or co-insurance. Not to mention setting up an EFT so you can actually get paid.
A single error in any one of these things can lead to delays. In some cases, insufficient coverage or coding errors can even lead to a claim rejection or claim denial!
To help keep you from feeling overwhelmed you need to educate yourself on some basic terms. This is a great first step in streamlining your speech-language pathology services.
Important Medical Coding & Billing Terms For Speech-Language Pathologists
Understanding the following terms and how they apply to medical coding and billing will go a long way toward reducing claim errors.
This is an acronym for “Electronic Medical Record/Electronic Health Record.” Every patient needs HIPAA-compliant digital versions of their traditional paper charts. This includes key patient information, notes, evaluations, and insurance info.
This is the insurance industry’s term for the invoice or bill that a provider such as yourself submits to them. It needs to include key information such as the NPI of the treating clinician, ICD-10 (diagnosis) codes, the correct CPT codes, as well as the patient’s insurance info.
A clearing house is essentially an intermediary coordinating payment between the insurance company, or public health institution and a provider like a speech-language pathologist. These professionals check claims for accuracy and then forward the claim information to the insurance company or payer institution via a “Claims Scrubbing” process.
This stands for “Explanation of Benefit” which is essentially a detailed form explaining why an insurance company is willing to accept or reject a claim. An EOB is typically sent to the patient and the provider, to make sure each is fully informed.
This is an acronym for Electronic Funds Transfer. In today’s age, it is essentially a direct deposit from the payer, which is much faster and more accurate than issuing a paper check.
This stands for “Electronic Remittance Advice” which is a battery of information from the insurance company about why a claim was or was not accepted. It typically comes included with an EOB.
This is a carefully itemized form that clearly explains the treatment that was provided. It also typically includes the diagnosis, the provider’s license number, EIN, and the patient’s insurance information.
The Credentialing Process For Speech-Language Pathologists
As a speech-language provider, you need to ensure that you’re credentialed with the insurance companies according to their terms. While this is a universal process, some insurance companies do have their own unique requirements. If you don’t provide them with the necessary credentialing information, they might reject or immediately deny any claim you submit.
Most insurance companies will require the following information for you to become credentialed and accept your claims.
- Employee Identification Number (EIN)
- National Provider Identifier (NPI)
- State license number
- Business name
- ASHA number
- Paperwork demonstrating your professional liability insurance coverage
- Taxonomy code, which is 235Z00000X for speech-language pathologists
Contracts & Fee Schedules
Once you’ve established your credentials with insurance providers you will then need to check the contract terms for each insurance company to get a clear understanding of their fee schedule. This might include their in-house terms for things like:
- Special requirements
- The acceptable session length for specific CPT codes
- Their clearing house requirements
Once you’re aware of all the terms, you can sign a contract to become a provider in their network. This gives you the ability to start accepting clients who carry that type of insurance.
However, before you can provide speech-language pathology therapy, you must verify a patient’s benefits using the number on their membership card or by going through your EMR. This includes collecting the following information regarding that patient such as:
This is a flat fee, usually ranging between $20 to $50 that is due at certain medical visits.
This is a stated percentage of the cost of the procedure, which the patient pays.
This is a specific amount that the patient must pay each year before insurance will pay. Coinsurance and co-payments may figure into this, depending on the plan.
Industry Specific Trends For Speech-Language Pathologists
There are several key changes in the realms of medical billing and therapeutic services that pertain to SLP services. Understanding these changes will go a long way toward preventing claim delays, and questions, and reducing the risk of claim denials.
SLP & PT Services Are Combined Under Targeted Review Threshold
For decades rehabilitation therapy services have been subject to a predetermined allotted amount for each reporting year under Medicare Part B. However, SLP and PT services are not combined, with the allotted amount for speech-language pathology services being $2,110. This includes any physical therapy services a Part B beneficiary receives throughout the year.
After that, any claims that happen to exceed this threshold require the provider to affix a special KX modifier. This denotes the “Medical Necessity” of continued treatment and thus, receive reimbursement for additional services.
Now that PT and SLP services count toward the same threshold amount, all speech-language pathologists need to inquire about any physical therapy services that a patient has received as part of their Medicare Part B coverage.
As an SLP you can contact your MAC to check on a patient’s progress toward their allotment cap. Though they might not have a 100% accurate figure if the patient has recently received PT services
It’s also worth noting that there is a second threshold of $3,000. At that point claims that exceed this amount could be subject to a targeted manual medical review.
Medicare Coverage Doesn’t Pay For Student-Led Services
The Medicare Benefit Policy Manual, in chapter 15 notes that “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.”
This means that student participation in a speech-language pathology treatment service doesn’t automatically make it non-reimbursable. Furthermore, section 230. B also states that students can only assist in services that are rendered by a licensed SLP or that they can deliver services under the direct guidance and supervision of the licensed provider. This includes group therapy services.
ASHA Policies For Clinical Fellows
The American Speech–Language–Hearing Association notes that “The student policy doesn’t apply to clinical fellows who are practicing in States which grant clinical fellows temporary or provisional licensure. Though in States without such licensure, Medicare treats clinical fellows as graduate students requiring ‘in the room’ supervision.”
Medicare Doesn’t Require SLP Referral From A Physician
While a lot of private insurance companies do require referrals for SLP services from a primary care physician, Medicare does not. Instead, Medicare coverage allows an SLP to evaluate a patient, establish a plan of care, and begin treating, without having to first obtain a physician referral.
Yet ASHA notes in their Medicare FAQ guide that SLPs “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.”
This also allows for the physician or speech-language pathologist to make minor modifications to the plan of care. However, the SLP is not permitted to significantly alter it without receiving recertification from the physician.
SLP Use of 97000 Series CPT Codes
The 97000 series of CPT codes are typically used to bill for PT services. However, SLPs can use this series of codes as well, under Medicare where CPT codes 97129, which covers “Cognitive Function Intervention for an initial 15-minute session.
An SLP can also use CPT code 97130 for “Cognitive Function Intervention, for each additional 15 minutes, when treating cognitive disorders. Yet 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.”
It’s important to remember that the 97000 series of CPT codes are typically held in reserve expressly for physical medicine, some SLPs may struggle to receive reimbursement for them. Using codes from both the 92000 and 97000 series on the same claim could result in unbundling, which Medicare does not allow.
Compliance With The National Correct Coding Initiative
Speech-language pathologists are also noted in the National Correct Coding Initiative (NCCI) manual which states that they “should not report CPT codes 97110, 97112, 97150, 97530, or 97129 as unbundled services included in the services coded as 92507, 92508, or 92526.”
Yet there are some cases where the use of codes from both series can be utilized. This is typically part of a cooperative treatment process involving multiple disciplines such as a physical therapist and a speech-language pathologist on the same date of service. In this exception, the providers m 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.
Assistant-Led Speech Services Aren’t Covered By Medicare
Medicare specifically doesn’t cover services provided by speech-language pathology assistants, which aren’t deemed to be “Medically Necessary.” This is a rule that catches a lot of SLP and occupational therapy providers off guard.
Though when it comes to commercial payers, and traditional insurance providers you should always check with each entity’s individual policyholder or their insurance company to confirm that they will cover SLP-Assistant-led services in their reimbursement schedule. Though you shouldn’t be surprised if the insurance company’s reimbursement policies are closely aligned with Medicare’s.
Accurate Documentation For Speech Language Pathology Services
Accurate documentation is a critical facet of any speech-language pathologist’s duties. It has a direct impact on medical billing and reimbursement. Each payer or public health institution might have its own documentation requirements. So it’s wise to always confirm this information whenever you become credentialed with a new insurance company or a public health institution like Medicare.
Important information to document includes:
- The patient’s medical history
- The diagnostic process that led to the diagnosis
- Findings that communicate the necessity of your care.
- Observations of the patient’s responses to treatment.
- Incorporate standardized tests and measurements when applicable
- Provide a sound reason why the treatment or proposed treatment is medically necessary
Consider Using A Medical Billing Specialist
A lot of speech-language pathologists will turn to using a third-party agency like Operant Billing Solutions to handle their medical billing needs. This ensures that you have the time you need to focus on diagnosing and treating the patients who rely on your care.
You can also rest easy knowing that our medical billing specialists are going over every claim with an expert eye to make sure all the information and documentation are included. This greatly reduces the risk of any one claim suffering rejection or outright denial. It also boosts the consistency of your revenue stream, while giving you more time to serve more patients.