Billing, Coding, & CalculatingFees: Finding Success

Janet McCartyAmerican Speech-Language-Hearing Association

Today’s Agenda

BILLING: Learn how to bill for yourservices.

CODING: Learn the codes that describethe services you provide. Use thesecodes to communicate with healthplans.

CALCULATING FEES: Learn how todetermine fees for your services.

BILLING: Superbills

Use a Superbill (Billing, Coding, Charges) List ICD-9 and CPT codes used most often in

your practice Provide patient information Assign a diagnosis (ICD-9 code) Assign a treatment (CPT code) Provide provider information Total Charges: ___________

ICD-9 & CPT Codes

ICD-9 (International Classification ofDiseases) codes describe the diagnosis

CPT (Current Procedural Terminology)codes describe procedures performed

Filing A Claim

Clinician decides whether patient orprovider files claims

If the patient files, you will need toprovide a bill with CPT & ICD-9 codes,charges, and supporting documentation

If you have a signed agreement withthe health plan, you may need to file

Remember…

Health plan coverage is an arrangementbetween the patient and health plan.Clinicians provide necessarydocumentation, but always make it clearto patients that they are ultimatelyresponsible for payment.

Review Patient’s Policy

Are audiology or speech-languageservices covered?

Claim decisions are based on contractwording. Is coverage clear or vague?

Filing A Claim

Be sure to obtain patient permission tosupply the health plan with relevantdocumentation

Contact Provider Relations

What is your provider status? Is your setting recognized (private

practice, university clinic)? Do you need a provider #? What documentation is necessary? Pre-authorization needed?

National Provider Identifiers(NPIs)

Effective May 2007, providers andorganizations defined as covered entitiesunder HIPAA will be required to have an NPI

NPI will replace current health provider #s The Web site for on-line application for

obtaining an NPI: https://nppes.cms.hhs.gov ASHA Web site for NPI information:

http://www.asha.org/members/issues/reimbursement/hipaa/NPI.htm

Billing Policies

Q. Can I waive co-payments?A. Usually not. Payers view the routine

waiver of patient payments as a breachof contract. Medicare/Medicaid co-paywaivers are not allowed and are viewedas false claims.

Waiving Co-pays

If provider’s fee is $100, but theMedicare 20% co-pay is waivedroutinely, the federal gov’t. saysMedicare should be billed $64 (80% of$80 vs. 80% of $100), and submitting a$100 claim is a false claim.

Can I offer a sliding scale?

Yes. Be sure to have a defined policyand procedure for consistentadministration. Have a written policy that establishes

guidelines for determining a patient’sindigency.

Contact local welfare clinics to learn thecommunity standard.

Medicare/Medicaid allows for limiteddocumented indigency.

Examples of Health CareProvider Fraud

Billing for services not performed Falsifying a patient’s diagnosis to justify

tests Upcoding, or billing for a more costly

service than the one performed Unbundling, or billing for each stage of

a procedure as if it were separate

Office Billing Policies

Providers should monitor their practices toensure compliance with all applicable federaland state laws when determining billingpolicies.

For more information on Billing Policies, go toThe ASHA Leader Online athttp://www.asha.org/about/publications/leader-online/archives/2006/060905/060905a.htm

CODING

You must be able to support your codingdecisions with patient history, physicianreferral information, evaluation results,and other documentation that supportsyour professional judgment as to thecause of the patient’s condition andrequired treatment.

Coding A Diagnosis

Originally, coding allowed retrieval ofinformation by diagnoses for purposes ofmedical research and education. “Codingtoday is used to describe the medicalnecessity of a procedure.”

From: ICD-9-CM Volumes 1&2, p. 3

ICD-9 Coding

Determine a diagnosis based on testresults and assign a diagnostic code

Assign the best, or most appropriatediagnostic code

Be able to support the assigned code

ICD-9 Coding

Determine the highest level ofspecificity, which means using the 5th

digit. For example: Don’t use 784.6 (symbolic dysfunction).

Instead, use 784.60 (symbolic dysfunction,unspecified), or 784.69 (other; agraphia,…,apraxia).

Coding To 5th Digit

Keep in mind that 784.60, 784.61, 784.69are subclassifications of 784.6, so whenyou use those codes, you are notexcluding 784.6.

Coding To 5th Digit

Assign 3 digits when there are no 4digit codes.

Assign 4 digit codes if there is no 5th

digit subclassification. Assign the 5th digit subclassification

code for those categories where itexists.

Coding Normal Results

Many payers will not reimburse for evaluationresults reported “within normal limits.”

When coding an uncertain diagnosis(“suspected,”“rule out”), code the conditionas if it existed.

When testing produces a normal result,report the sign & symptom or chief complaintas the primary diagnosis.

Signs/Symptoms Associated WithAphasia; Language Disorders

Difficulty speaking 784.5 (speech disturbance)

Difficulty understanding spokenlanguage 784.3 (aphasia)

Cognitive deficits 784.60 (symbolic dysfunctions,

unspecified)

Signs/Symtoms AssociatedWith Audiology

Difficulty hearing in noise 389.9 (unspecified hearing loss)

Acoustic trauma 388.11 (acoustic trauma, explosive, to

ear) Delayed speech/language

315.39 (dev. articulation disorder) or783.42(delayed milestones; latetalker/walker

Coding Procedures

Use CPT codes to describe the serviceor treatment

Choose the CPT procedure code thatbest describes the services

CPT Coding: TimeComponents

There are no time componentsassociated with many SLP/AUDprocedure codes

Asking for time-based codes can berisky

Time is already factored into relativevalue process

CPT Coding: Using Modifiers

-22 Unusual services: the serviceprovided is greater than that usuallyrequired

-52 Reduced services: procedure ispartially reduced

CPT Coding

Understand the CPT Process Step 1 & Step 2

The CPT Process –Step 1

Owned by the American MedicalAssociation (AMA)

ASHA’s Health Care EconomicsCommittee proposes new codes

Multiple-step process for approving newcodes

Collaboration with related organizations

The CPT Process –Step 2

1. The AMA Relative Value Committee“values”the procedure, or new code,and makes a recommendation to CMS(Centers for Medicare/Medicaid)

2. CMS revalues the procedure takinginto account: work, time involved,professional liability, equipment &supplies; then assigns reimbursement

CALCULATING FEES

Health care providers have someflexibility when setting private fees.

Clinicians can choose a pricingphilosophy, and then gather availablecharge information to establish a feeschedule and negotiate health carecontracts.

Choosing A Pricing Philosophy

1. Market-driven approach: Known as UCR(usual, customary, reasonable) ties medicalpricing to industry trends in localcommunities; assumes patients are price-sensitive.

2. Relative value approach: Fees are tied to“worth”of a procedure and considers skill,time, risk. Medicare Physician Fee Scheduleuses the relative value method.

Available Fee Data Compare your fees with the Medicare

Physician Fee Schedule. Use the fee data (from Milliman) found in

ASHA’s Negotiating Health Care Contracts &Calculating Fees to determine average costsby CPT code.

The Milliman fee data cannot be directlyshared beyond ASHA members, but can beused as a reference for negotiating rates.

National Fee Analyzer www.ingenixonline.com

Calculating Fees: WARNING

Setting prices in collusion with colleaguesis illegal. Avoid price-fixing, such asdiscussing fees with local providers.

Understanding Fee Data

50th percentile: 50% of charges arebelow this rate; 50% of charges are ator above this rate.

75th percentile: 75% of charges arebelow this rate; 25% of charges are ator above this rate. (Ingenix)

Milliman data: average charges forservices

Calculating the MedicareReimbursement Rate

CPT 92585 (Auditory Evoked Potentials;comprehensive)

Physician Work RVUs 0.50Practice Expense RVUs 2.06Malpractice RVUs 0.17TOTAL RVUs 2.73

2.73 x $37.89 = $103.43

Fee Data

CPT 92506 (Speech & Language Eval.)

50th percentile: $144.3675th percentile: $210.47Medicare rate: $132.26Milliman data: $152.71

Fee Data

CPT 92507 (Speech-Lang. Treatment)

50th percentile: $68.8275th percentile: $100.33Medicare rate: $62.53Milliman data: $117.66

Fee Data

CPT 92557 (Comprehensive AudiometryEvaluation)

50th percentile: $96.1475th percentile: $118.22Medicare rate: $49.65Milliman data: $86.04

Fee Data

CPT 92567 (Tympanometry)

50th percentile: $37.7075th percentile: $46.36Medicare rate: $21.98Milliman data: $39.96

Establishing Fees

Establishing fees takes care. Fees that aretoo high will lead to disputes withpatients and payers. Fees that are toolow will result in inadequatereimbursement.

Negotiating BetterReimbursement Rates

5 –Step Process

Negotiating BetterReimbursement Rates

Step 1Determine the most common CPT

codes-Codes that account for 75% of yourtotal practice charges-Record the # of times you providedthe service over 12-month period (CPT92557: frequency 500)

Negotiating Better Rates

Step 2Determine your top payers

-Focus on 3-4 payers = bulk of yourreimbursement-Medicare/Medicaid use established feeschedules and do not negotiate

Negotiating Better Rates

Step 3Determine your reimbursement for

each code-Note how much each payer allows foreach code on your list-Calculate each payers’reimbursementas a % of Medicare’s fee schedule

Calculate Payer Rate As A %of Medicare Rate

113%$25.00$21.9892567-Tymp.

PayerPaymentas a % ofMedicare

HealthPlan Rate

MedicareAllowedAmt.

CPT

Negotiating Better Rates

Step 4Review your fees for each code

-Calculate your fees as a percentage ofMedicare’s rates-Update your fee schedule annually

Calculate Your Fees As A % ofMedicare’s Rate

159%$35.00$21.9892567

Your feeas a % ofMedicare

YourCurrentFee

MedicareAllowedAmt.

CPT

Negotiating Better Rates

Step 5Organize and analyze the data

-Compare rates between plans-If payer reimburses in full, may mean yourfees are too low. Plan may be willing to paymore.-Consider raising fees or standardize all yourfees at some % of Medicare, say 125%

Negotiating Better Rates

Organize & analyze the data-Is one plan’s rates lower, or is onecode paid at a much lower % ofMedicare than others?-Establish target reimbursement ratesfor your negotiations, say 120% ofMedicare

Develop An Action Plan

Negotiate individual fees: Your first contactmight be Provider Relations rep, then theContracting Manager

Drop the plan: Rates too low, no longeraccept patients. Patients may find anotherprovider, or complain to their employer.

Close to new patients if you don’t want todrop a health plan completely.

Coding Examples

Let’s look at some patient cases and codethe service and diagnosis.

Coding Example

Case: Patient seen for voice prosthesisevaluation and fitting. ICD-9 diagnostic code: from physician 784.41 (aphonia) primary vs. secondary diagnosis CPT procedure code: 92597 (eval for

use/fitting of voice prosthesis)

Coding Example

Case: Patient needs modification oftrach-esophageal prosthesis duringfollow-up visit ICD-9 code: from physician 784.41 - aphonia CPT code: 92507 (speech-language

treatment).

Coding Example

Case: Audiological eval revealssensorineural hearing loss bilaterally.Middle ear function WNL. ICD-9 code: 389.18 (sensorineural hearing

loss of combined types, bilateral) CPT code: 92557, 92567, 92568, 92569

(comprehensive aud., tymp., acousticreflex testing, decay)

Coding Example

Case: A 35 y/o male has impairedlanguage & cognitive skills after headinjury. ICD-9 code:784.69 (symbolic dysfunction,

coded to 5th digit) CPT code: 92506 (speech-lang. eval.)

Coding Example

Case: 35 y/o male iscognitive/language impaired due tohead injury ICD-9 code: 784.69 CPT code: 92507 (speech-lang. treatment)

OR 97532 (development of cognitive skills to

improve attention, memory…)

Coding Example

Case: 4-month old boy is seen forauditory brainstem response (ABR) torule out hearing impairment. ICD-9 code: 389.18 (sensorineural hearing

loss of combined types; bilateral) or 389.9(unspecified hearing loss)

CPT code: 92585 (auditory evokedpotentials); 92588 (evoked otoacousticemissions; comp.); 92567 (tympanometry)

Coding Example

Case: 5 y/o with unintelligible speech isdiagnosed with language impairmentand verbal apraxia. ICD-9 code: 784.69 (apraxia) Verbal

apraxia tests confirm this diagnosis. CPT code: 92506 (speech-lang. eval.)

Coding Example

Case: Auditory rehabilitation for a 66y/o female. ICD-9 code: 389s (Hearing Loss) CPT code: 92633 (auditory rehabilitation

post-lingual hearing loss)

Coding Example

Case: Patient has normal hearing.

Q. How do you code the diagnosis?A. Code the referring diagnosis.

(For example, 388.30/tinnitus;389.9/unspecified hearing loss)

Coding Example

Case: Patient seen for bedsideswallowing assessment. ICD-9 code: 787.2 (dysphagia) CPT code: 92610 (evaluation of

oral/pharyngeal swallow function)

Coding Example

Case: SLP performs a speech-languageevaluation and treatment on the same date ofservice. What would you code?

Answer: Eval (92506) and treatment (92507)are now allowed on the same date of servicewith modifier -59 (distinct procedural serviceperformed on same day).

Coding Example

Case: SLP participates in fiberopticendoscopy but does not actually insertthe endoscope. What would you code?

Answer: 92610 (bedside swallow)because SLP did not actually insert theendoscope.

A Great Resource

ASHA’s Billing and Reimbursement WebSite: www.asha.org/members/issues/reimbursement/

Coding for Reimbursement Private Health Plans Medicare Medicaid

Questions

Billing questions?

Coding questions?

Fee questions?