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  • Coding and ICD-10SHANNON BUTKUS, M.S. CCC-SLP, FNAP

  • Fun Facts

    u I have 16 years experience as a speech pathologist.

    u Ive been in private practice for the past 9 years.

    u I am currently Vice President for Social & Governmental Policy for TSHA.

    u I am also the Texas State Advocate for Reimbursement for ASHA.

    u Fanatical football fan!

  • Disclosure Statement

    Financial relationship:

    u The New Mexico Speech-Language Hearing Association paid travel related expenses.

  • Framework for Todays Presentation

    u General Coding Principles

    u ICD-10-CM

  • Healthcare Coding Systems

    1. Current Procedural Terminology (CPT) Codes: Describe what we do with the patient

    2. Health Care Common Procedures Coding System (HCPCS) Level II Codes: Supplies, Equipment and Devices

    3. International Classification of Disease (ICD-10) Codes: Describe why the patient needs treatment

  • Why Do We Code?

    1. Coding provides a common language for providers, insurance companies, and benefits administrators.

    2. Coding standardizes reporting procedures.3. Coding provides data that enables researchers /

    healthcare organizations to:u Evaluate quality

    u Determine utilization patterns

    u Examine healthcare costs

    u Establish fee schedules

    u Compile basic health statistics

  • Coding PrinciplesCPT Codes

    General Facts: CPT codes are copyrighted by the American Medical

    Association and updated annually.

    CPT codes describe how to report procedures.

    Every medical, surgical, and diagnostic procedure is assigned a five digit code.

    There are limitations on the use of codes.

    o National Correct Coding Initiative (NCCI) Edits

    o Medically Unlikely Edits (MUE)

    o Outpatient Code Editor (OCE)

  • Coding Principles CPT Codes

    Speech Language Pathologists:Most CPT codes for speech-language pathologists are procedure based. The code is reported one time regardless of the length of the session.

    The following CPT codes are time-based codes:o Speech-generating device (SGD) evaluation (first hour)

    o Each additional 30 minutes for a SGD evaluation

    o Aphasia evaluation, per hour

    o Aural rehabilitation evaluation, first hour

    o Each additional 15 minutes of the aural rehabilitation evaluation

  • Coding PrinciplesCPT Codes NCCI Edits

    NCCI edits The NCCI edits were developed by the Centers for

    Medicare & Medicaid Services (CMS)

    The NCCI edits are updated quarterly

    Used to determine which CPT codes may be paired together on the same date of service.

  • Coding PrinciplesCPT Codes NCCI Edits

    NCCI editsThe goal of the NCCI edits is to eliminate mutually exclusive code pairings and codes considered to be components of more comprehensive services.

    o Example: A provider may not bill CPT 92522 on the same date of service as CPT 92523. CPT 92522 is a component of CPT 92523

    o Example: A provider may not bill CPT 92607 (SGD evaluation) on the same date of service as CPT 92597 (voice prosthetic evaluation)

  • Coding PrinciplesCPT Codes NCCI Edits

    NCCI edits

    The NCCI edits are used when reporting Medicare Part B Claims.

    The Patient Protection and Affordable Care Act of 2010 requires that state Medicaid programs adopt the NCCI edits for Medicaid claims.

    Most commercial insurers also require the use of the NCCI edits.

  • Coding PrinciplesCPT Codes Outpatient Code Editor

    Outpatient Code Editor (OCE) These apply only to hospital

    outpatient services Usually very similar to the NCCI

    edits They are published quarterly, one

    quarter after the revised NCCI edits are implemented

  • Coding PrinciplesCPT Codes Edit Tables

    http://www.asha.org/Practice/reimbursement/coding/CCI-Edit-Tables-SLP/

  • Coding PrinciplesCPT Codes Medically Unlikely Edits

    Medically Unlikely Edits (MUE) The MUE for any given code determines the maximum

    number of times per day that the code can be reported for the same patient.

    MUEs are used when reporting Medicare Part B Claims

    The Patient Protection and Affordable Care Act of 2010 requires that state Medicaid programs adopt the MUEs for Medicaid claims.

    Most commercial insurers also require the use of the MUEs.

  • Coding PrinciplesCPT Codes Medically Unlikely Edits

    http://www.asha.org/Practice/reimbursement/coding/Medically-Unlikely-Edits-SLP/

  • Coding PrinciplesCPT Codes

    Speech Language Pathologists:

    ASHA resources:http://www.asha.org/practice/reimbursement/coding/SLPCPT.htm

    http://www.asha.org/practice/reimbursement/coding/SLPCodeInfo/

    NCCI Edits:

    http://www.asha.org/Practice/reimbursement/coding/CCI-Edit-Tables-SLP/

  • Coding PrinciplesCPT Codes

    Audiologists: ASHA resources:

    http://www.asha.org/aud/articles/hcecanswers/

    NCCI Edits:

    http://www.asha.org/Practice/reimbursement/coding/CCI-Edit-Tables-Audiology/

  • Coding PrinciplesModifiers

    Modifiers GN: Required on Medicare Part B claims for speech-

    language pathology or dysphagia serviceso Also required by some commercial insurers and state

    Medicaid programs

    -22: May be used to indicate a procedure took substantially longer than is typical.o Do not over use this code

    -52: Should be used with an abbreviated procedureo Example: The -52 modifier should be used with procedure

    code 92523 if the evaluator does evaluate speech sound production

  • Coding PrinciplesModifiers

    Modifiers -59: Is used to establish one procedure as distinct from another procedure

    when billed on the same date of service by the same providero -59 is being revised by CMS because of the risk of incorrect coding.

    Source:http://www.asha.org/Practice/reimbursement/medicare/SLP_coding_rules/#CCI

    http://www.asha.org/News/2014/Medicare-Clarifies-Billing-Modifiers-for-Therapy-Services/

  • Coding PrinciplesMedicare Part B G Codes

    G Codes CMS requires that providers report non-payable G-codes for Part

    B Medicare beneficiaries. G-codes must be accompanied by severity/complexity

    modifiers. Include the G code and severity modifier with every evaluation

    and every 10th treatment day.

    Source: http://www.asha.org/Practice/reimbursement/medicare/G-Codes-and-Severity-Modifiers-for-Outcomes-Reporting/

    Source: http://www.asha.org/Practice/reimbursement/medicare/Claims-Based-Outcomes-Reporting-for-Medicare-Part-B/

  • Coding PrinciplesMedicare Part B G Codes

    http://www.asha.org/Practice/reimbursement/medicare/G-Codes-and-Severity-Modifiers-for-Outcomes-Reporting/

  • Coding PrinciplesMedicare Part B G Codes

    http://www.asha.org/Practice/reimbursement/medicare/G-Codes-and-Severity-Modifiers-for-Outcomes-Reporting/

  • Coding PrinciplesMedicare Part B Severity Modifiers

    http://www.asha.org/Practice/reimbursement/medicare/G-Codes-and-Severity-Modifiers-for-Outcomes-Reporting/

  • Coding PrinciplesMedicare Local Coverage Determinations

    Local Coverage Determinations (LCDs): LCDs are coverage guidelines created by the local

    Medicare Administrative Contractor (MAC) They provide rules for determination of coverage in the

    absence of a national policy.

    They also provide clarification of national policies. Providers should monitor LCDs closely

    Source: http://www.asha.org/practice/reimbursement/medicare/McareCoverageSLP/

  • Coding PrinciplesPhysician Quality Reporting System

    Physician Quality Reporting System (PQRS): CMS designed the PQRS to improve the quality of care

    Medicare beneficiaries receive.

    PQRS is designed to track practice patterns.

    As a result of the passage of the ACA, provider participation in the PQRS program is mandatory.

    Participation starts over each calendar year.

  • Coding PrinciplesPhysician Quality Reporting System

    Physician Quality Reporting System (PQRS):

    Failure to participate results in a financial penalty.

    Providers that failed to report PQRS quality codes for more than 50% of their patients in 2014, will be assessed a 2% penalty on all claims in 2016.

    Penalties may change from year to year.

    Source: http://www.asha.org/practice/Health-Care-Reform/Physician-Quality-Reporting-System/

  • Coding PrinciplesPhysician Quality Reporting System

    Physician Quality Reporting System (PQRS):

    Source for Audiologists: http://www.asha.org/Advocacy/audiologyPQRI/

    Source for Speech Pathologists:

    http://www.asha.org/Practice/reimbursement/medicare/Physician-Quality-Reporting-System-for-SLPs/

  • Coding PrinciplesValue-Based Payment Modifiers

    Value-Based Payment Modifiers (Medicare): The application of value-based payment modifiers for 2016

    has been eliminated.

    Value-based payment modifiers would have put SLPs and audiologists at risk for payment reductions of up to 6% for .

    Source: http://leader.pubs.asha.org/article.aspx?articleid=2432361

  • Coding Principles HCPCS Level II Codes

    HCPCS Level II codes: HCPCS codes identify supplies, devices, equipment

    and procedures not found in the CPT system.

    ASHA Resources for SLPs: http://www.asha.org/practice/reimbursement/coding/hcpcs_slp/

    ASHA Resources for Audiologists:

    http://www.asha.org/Practice/reimbursement/coding/hcpcs_aud/

  • Coding Principles Physical Medicine Codes

    Physical Medicine Codes: CMS has determined that SLPs may not report CPT

    code 97110 (therapeutic exercises) and CPT 97112 (neuromuscular reeducation).

    SLPs may report CPT 97532 (cognitive therapy) and CPT 97533 (sensory integration)

    Source:http://www.asha.org/Practice/reimbursement/medicare/SLP_coding_rules/#CCI

  • Coding PrinciplesOut with the old ~ ICD-9-CM

    Why did we switch? ICD-9 was more than 30 years old.

    ICD-9 was running out of codes.

    ICD-9 contained obsolete/outdated terms.

  • Coding PrinciplesIn with the new ~ ICD-10-CM

    Why did we switch? ICD-10 has 160,000 codes

    New ICD-10 allows for greater specificity.o 3-7 alphanumeric characters

    Code descriptors have more detail reducing the change for error

    ICD-10 allows for better tracking of incidence/prevalence of disease.

  • Coding PrinciplesIn with the new ~ ICD-10-CM

    What does this mean? Providers may experience payment delays or denials.

    CMS is not requiring that providers obtain updated orders from the PCP that contain the ICD-10 code.

    Providers should coordinate with the PCP to obtain the appropriate ICD-10 code.

  • Coding PrinciplesIn with the new ~ ICD-10-CM

    What does this mean? For the first 12 months, CMS is providing some flexibility to

    providers for Part B Medicare claims so long as the provider uses a valid code from the right family is selected

    Source: http://leader.pubs.asha.org/article.aspx?articleid=2432370

  • Coding PrinciplesICD-10

    The ICD-10 Code should match the CPT code Example: the SLP should not code F80.0

    (phonological disorder) with 92526 (treatment of swallowing dysfunction and/or oral function for feeding)

    F80.0 should pair with 92507

    Always code to the highest specificity.

  • Coding Principles ICD-10

    Report diagnosis codes in the correct order: Primary Code: reason for the visit

    Secondary Code: medical diagnosiso Secondary diagnosis codes are required when the patient

    presents with an underlying neurological or organically based speech, language, hearing, vestibular, or swallowing disorder

    o The physician should provide documentation of the underlying medical diagnosis

    NOTE: This is a general coding principle. A payer source may instruct you to code the medical diagnosis first. If so ask them to put their recommendation in writing.

  • Coding PrinciplesICD-10

    Sequencing: There are codes that require specific sequencing based on

    additional notes listed in the the ICD-10 code list.

    These variations are clearly identified at the etiology ICD-10 code and the ICD-10 code that identifies the manifestation

    Example: If the SLP assigns a diagnosis of dysphagia from the R13.1 series, the accompanying code first note directs the SLP to first list a separate code in the I69 series, when appropriate. Conversely, the I69 series is accompanied by a use additional note instructing the SLP to identify the type of dysphagia in the R13.1 series

  • Coding PrinciplesICD-10

    Excludes1 Notation: Excludes1: Indicates that the codes excluded should

    never be used at the same time as the code above the Excludes1 notation.

    The Excludes1 notation is used when two codes cannot co-occur such as a congenital form of a condition versus the acquired form of the same condition.

    Example: H93.25 (central auditory processing disorder) has an excludes1 notation that prevents a provider from pairing it with F80.2 mixed-receptive language disorder.

  • Coding PrinciplesICD-10

    Excludes2 Notation: Excludes2: Indicates codes that may be listed together

    because the conditions may co-occur, even if they are unrelated.

    When the Excludes2 notation is present, the provider may use both the code and the excluded code together.

  • Coding PrinciplesICD-10

    Unspecified and Other Codes: Not otherwise specified (NOS): There is insufficient

    information in the medical record to assign a more specific diagnosisu Avoid using NOS codes when possible

    Other codes: There is sufficient information in the medical record but no code exists for the specific condition

  • Coding PrinciplesICD-10

    Coding normal results: If results of diagnostic assessment indicate normal

    findings, code symptoms that led to the referral.

    List additional codes that describe co-occurring conditions.

    Clinical report should reflect the reason for the referral as well as the findings.

  • Coding PrinciplesICD-10

    Do not:1. Code just because you know the code will get paid

    2. Code conditions that were previously treated and no longer exist

    3. Code suspected, questionable, or probable diagnoses

    Source: http://www.asha.org/Practice/reimbursement/coding/ICD-10-CM-Coding-FAQs-for-Audiologists-and-SLPs/

  • Coding PrinciplesICD-10 ~ Audiology

    Coding for CAPD: Diagnosis of CAPD: Use code H93.25

    Coding for Bilateral Hearing Loss: Per ASHA: Unilateral hearing loss codes that include

    unrestricted hearing on the contralateral side arecreating a problem for coding different types ofhearing loss in each ear. There is a proposal to theNCHS to add new codes for those times when there isrestricted hearing loss on the contralateral side.

  • Coding PrinciplesICD-10 ~ Audiology

    Coding for Bilateral Hearing Loss:u In the mean time, the only way to code two different

    hearing losses is to us the unspecified hearing loss codes, one for each ear according to the type, as follows:o H90.5: Unspecified sensorineural hearing losso H90.8: Mixed conductive and sensorineural hearing

    loss, unspecifiedo H90.2: Conductive hearing loss, unspecified

    Source: http://www.asha.org/Practice/reimbursement/coding/ICD-10-CM-Coding-FAQs-for-Audiologists-and-SLPs/

  • Coding PrinciplesICD-10 ~ Audiology

    Coding for a Failed Newborn Hearing Screening: H91.90: unspecified hearing loss, unspecified ear

    You could also use another code in the H91.9 series

    When there is not enough information to assign a more specific diagnosis, use an unspecified code.

    Source: http://www.asha.org/Practice/reimbursement/coding/ICD-10-CM-Coding-FAQs-for-Audiologists-and-SLPs/

  • Coding PrinciplesICD-10 ~ Speech Pathology

    Commonly Used Speech Codes: F80.0: Phonological disorder

    F80.1: Expressive language disorder

    F80.2: Mixed receptive-expressive language disorder

    F80.4: Speech and language development delay due to hearing loss; also code the type of hearing loss (H90.-, H91.-)

    F84.0: Autistic Disorder

    F84.5: Aspergers Syndrome

  • Coding PrinciplesICD-10 ~ Speech Pathology

    Commonly Used Speech Codes: R47.89 Other speech disturbances R48.2 Apraxia R48.8 Other symbolic dysfunctions, acalculia, agraphia

    NOTE: Organic-based speech, language or swallowing problems, such as those related to cleft lip or cerebral palsy, are coded using the R series codes. When there is an underlying medical condition that contributes to the speech and/or language deficit, that secondary code should be included on the claim.

    Source: http://www.asha.org/Practice/reimbursement/coding/ICD-10-CM-Coding-FAQs-for-Audiologists-and-SLPs/

  • Coding PrinciplesICD-10 ~ Speech Pathology

    u I69.020: Aphasia following non-traumatic subarachnoid hemorrhage

    u I69.120: Aphasia following non-traumatic intra-cerebral hemorrhage

    u I69.220: Aphasia following other non-traumatic intracranial hemorrhage

    u I69.320: Aphasia following cerebral infarction

  • Coding PrinciplesICD-10 ~ ASHA Resources

    ICD-10-CM FAQ:http://www.asha.org/Practice/reimbursement/coding/ICD-10-CM-Coding-FAQs-for-Audiologists-and-SLPs/

    ICD-10-CM Diagnosis Codes for Audiology and Speech-Language Pathology:

    http://www.asha.org/Practice/reimbursement/coding/ICD-10/

    Search for ICD-9 to ICD-10 Mapping Tool:http://www.asha.org/icdmapping.aspx

  • Coding PrinciplesICD-10 ~ ASHA Resources

    ICD-10 Diagnosis Code List for Audiologists:http://www.asha.org/uploadedFiles/ICD-10-Codes-Audiology.pdf

    ICD-10 Diagnosis Code List for Speech Pathologists:http://www.asha.org/uploadedFiles/ICD-10-Codes-SLP.pdf

    ASHA Email:

    [email protected]

  • Coding PrinciplesICD-10 ~ ASHA Resources

    ASHA State Advocate for Reimbursement (STAR): Michael Kaplan

    [email protected]

    ASHA State Advocate for Medicare Policy (StAMP): Julie Borrego

    [email protected]