Billing and Coding: Speech-Language Pathology

This article gives guidance for billing, coding, and other guidelines in
relation to local coverage policy Speech-Language Pathology.

**General Guidelines for Claims submitted to Part A or Part B MAC:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare. For services requiring a referring/ordering physician, the
name and NPI of the referring/ordering physician must be reported on the
claim. A claim submitted without a valid ICD-10-CM diagnosis code will be
returned to the provider as an incomplete claim under Section 1833(e) of the
Social Security Act. The diagnosis code(s) must best describe the patient's
condition for which the service was performed. For diagnostic tests, report
the result of the test if known; otherwise the symptoms prompting the
performance of the test should be reported.

**Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines**

An ABN may be used for services which are likely to be non-covered, whether
for medical necessity or for other reasons. Refer to CMS Publication 100-04,
Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with
modifier -GA, -GX, -GY, or -GZ, as appropriate.

The -GA modifier ("Waiver of Liability Statement Issued as Required by Payer
Policy") should be used when physicians, practitioners, or suppliers want to
indicate that they anticipate that Medicare will deny a specific service as
not reasonable and necessary and they do have an ABN signed by the beneficiary
on file. Modifier GA applies only when services will be denied under
reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e),
or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC
systems will automatically deny services billed with modifier GA. An ABN, Form
CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts
responsibility for payment. The -GA modifier may also be used on assigned
claims when a patient refuses to sign the ABN and the latter is properly
witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the
date of the ABN is required.



Modifier GX ("Notice of Liability Issued, Voluntary Under Payer Policy")
should be used when the beneficiary has signed an ABN, and a denial is
anticipated based on provisions other than medical necessity, such as
statutory exclusions of coverage or technical issues. An ABN is not required
for these denials, but if non-covered services are reported with modifier GX,
will automatically be denied services.



The -GZ modifier should be used when physicians, practitioners, or suppliers
want to indicate that they expect that Medicare will deny an item or service
as not reasonable and necessary and they have not had an ABN signed by the
beneficiary. If the service is statutorily non-covered, or without a benefit
category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN
is not required for these denials, and the limitation of liability does not
apply for beneficiaries. Services with modifier GY will automatically deny.

**Documentation Requirements**

The patient's medical record should include but is not limited to:

  * The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  * Relevant medical history
  * Results of pertinent tests/procedures
  * Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)



The patient's medical record must contain documentation that fully supports
the medical necessity for services included within this LCD. (See "Indications
and Limitations of Coverage.") This documentation includes, but is not limited
to, relevant medical history, physical examination, and results of pertinent
diagnostic tests or procedures. Not only should documentation describe the
condition of the patient that necessitates the skilled intervention of the
speech-language pathologist, but should also report clinical judgment and
describe the skilled nature of the treatment. Documenting the skilled
components of activities will assist in supporting that the services are
medically necessary.  
  
Documentation of speech language services, like other therapy services, must
be objective, clear, concise, and must show evidence of the beneficiary's
progress in meeting treatment goals. Documentation in the clinical record must
be descriptive, clearly related to functionality, and complement and correlate
with other disciplines. Medical necessity may not be established if there is
conflicting documentation between disciplines or widely fluctuating abilities
indicating an unstable condition. Prior level of functioning must be
documented and considered in the patient's treatment plan, to establish
reasonable goals for the patient's present condition. Statements such as
"mildly impaired to moderately impaired" or "fair plus to good minus" do not
offer sufficient objective and measurable information to support progress and
may result in denial of services as not medically necessary. Documentation of
discharge planning should be indicated early in the treatment plan.  
  
Where a valid expectation of improvement existed at the time services were
initiated, or thereafter, the services may be covered even though the
expectation may not be realized. Progress reports must document a continued
reasonable expectation that the patient's condition will improve
significantly, i.e., a measurable and substantial increase in the patient's
level of communication, independence, and functional competence compared to
the level when treatment was initiated. Documentation should include
improvements, setbacks, and intervening medical complications--whatever is
deemed pertinent to justify the need for continued intervention.  
  
For additional information on Medicare documentation requirements for speech-
language pathology services see: CMS Publication 100-02, _Medicare Benefit
Policy Manual_ , Chapter 15, Section, 220, including the subsections under
Section 220.