Article - Billing and Coding: Speech-Language Pathology (A57040)

CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1833(e) of Title XVIII of the Social Security Act prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1835(2)(D) of Title XVIII of the Social Security Act lists requirements for certification and recertification of outpatient speech-language pathology services.Section 1862(a)(1)(A) of Title XVIII of the Social Security Act excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1862(a)(7) excludes routine physical examinations, unless otherwise covered by statute.Code of Federal Regulations:42 CFR, Section 410.61 describes plan of treatment requirements.42 CFR, Section 410.62 describes outpatient speech-language pathology services: Conditions and exclusions for Outpatient Speech Language Pathology (SLP).42 CFR, Section 485.705 describes personnel qualifications.CMS Publications:CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 12:40.4 Speech-language pathology servicesCMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15:220 Coverage of outpatient rehabilitation therapy services (physical therapy, occupational therapy, and speech-language pathology services) under medical insurance220.1 Conditions of coverage and payment for outpatient physical therapy, occupational therapy, or speech-language pathology services220.1.1 Outpatient therapy must be under the care of a physician/nonphysician practitioners (NPP) (orders/referrals and need for care)220.1.3 Certification and recertification of need for treatment and therapy plans of care220.1.4 Requirement that services be furnished on an outpatient basis230.3 Practice of speech-language pathology230.6 Therapy services furnished under arrangements with providers and clinicsCMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, Part 1:50.2 Electronic speech aidsCMS Pub. 100-03,Medicare National Coverage Determinations (NCD) Manual, Part 3:170.2 Melodic intonation therapyCMS Pub. 100-04,Medicare Claims Processing Manual, Chapter 5:10.2 Financial limitation20 HCPCS coding requirementCMS Pub. 100-04,Medicare Claims Processing Manual, Chapter 6,10.3 Types of services subject to the consolidated billing requirement for SNFsCMS Transmittal No. 111, Publication 100-02,Medicare Benefit Policy Manual, Change Request #6005, September 25, 2009, advises that speech-language pathology therapy services are covered CORF services if physical therapy services are the predominate rehabilitation services.CMS Transmittal No. 106, Publication 100-02,Medicare Benefit Policy Manual, Change Request #6381, April 24, 2009, advises that enrolled speech-language pathologists may bill for services provided on or after July 1, 2009.CMS Transmittal No. 1717, Publication 100-04,Medicare Claims Processing Manual, Change Request #6381, April 24, 2009, advises that enrolled speech-language pathologists may bill for services provided on or after July 1, 2009.CMS Transmittal No. 88, Publication 100-02,Medicare Benefit Policy Manual, Change Request #5921, May 7, 2008, Therapy Personnel Qualifications and Policies Effective January 1, 2008.Article TextThis 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 GuidelinesAn 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 RequirementsThe patients 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 historyResults of pertinent tests/proceduresSigned 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 complicationswhatever 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.