Today s Agenda. Coding and Reimbursement: Optimizing Your Reimbursement Montana Speech and Hearing Association October 21, 2016.

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Today s Agenda Coding and Reimbursement: Optimizing Your Reimbursement Montana Speech and Hearing Association October 21, 2016 Debbie Abel, AuD Manager, Coding and Contract Services Social Security

1395x] Definition of Medical Necessity Coding Systems CPT, ICD-10-CM, HCPCS codes for audiologists and speech-language pathologists Medicare: Requirements Enrollment PQRS MACRA Prevalent legal

Risk Screening #155 Falls Risk Plan of Care #226 Tobacco Use PQRS 2016 for speech-language pathologists PQRS 2017 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ICD-10 s ICD-10 common

Beneficiary Identifier (MBI) will be assigned to each beneficiary A new card will be issued no later than 4/18 Your systems will need to be able to transition to the MBI https://www.cms.

1 Today s Agenda Coding and Reimbursement: Optimizing Your Reimbursement Montana Speech and Hearing Association October 21, 2016 Debbie Abel, AuD Manager, Coding and Contract Services Social Security Act Definition of Audiologists and Speech-Language Pathologists Sec [42 U.S.C. 1395x] Definition of Medical Necessity Coding Systems CPT, ICD-10-CM, HCPCS codes for audiologists and speech-language pathologists Medicare: Requirements Enrollment PQRS MACRA Prevalent legal /ethical concerns Tools for revenue for audiologists as the hearing aid landscape changes Agenda PQRS 2016 for audiologists 3 previous measures retained (#261, #130, #134) New measures: #154 Falls Risk Screening #155 Falls Risk Plan of Care #226 Tobacco Use PQRS 2016 for speech-language pathologists PQRS 2017 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ICD-10 s ICD-10 common denials Prevalent ethical/legal concerns Thoughts for the changing audiologic landscape MACRA (2015) requires the elimination of Social Security Numbers from Medicare cards by April 2019 An Medicare Beneficiary Identifier (MBI) will be assigned to each beneficiary A new card will be issued no later than 4/18 Your systems will need to be able to transition to the MBI Additional Resources: For additional information on the Social Security Number Removal Initiative (SSNRI) home page click here: Other helpful links: SSNRI MBI format link: PDF.PDF SSNRI Health & Drug Plans: Drug-Plans/Health-and-drug-plans.html SSNRI States: SSNRI Partners /Employers: SlidesCarnival icons are editable shapes. 1

2 SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. 2

Title XVIII of the Social Security Act, section 1862

no payment may be made under Part A or Part B for any

reasonable and necessary for the diagnosis or treatment of

malformed body member The three coding systems support each

(and/or HCPCS) AND ICD codes If billing HCPCS codes May also

of one ICD code with each claim; more with the ICD-10s 3

3 SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. Medicare s Definition of Medical Necessity Coding Thoughts: Title XVIII of the Social Security Act, section 1862 (a)(1)(a): Notwithstanding any other provisions of this tile, no payment may be made under Part A or Part B for any 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 The three coding systems support each other and must be reported for filing claims Required: CPT (and/or HCPCS) AND ICD codes If billing HCPCS codes May also be billing CPT simultaneously Always have to have a minimum of one ICD code with each claim; more with the ICD-10s 3

Where to Purchase? SlidesCarnival icons are editable shapes. AMA bookstore: https://commerce.

category_id=cat1150004& navaction=jump Optum 360: https://www.optumcoding.com/campaign/?

s=cpt+code+book&ie=utf8&qid=1437795274&rnid=1000 Thoughts: Considerations: Case-building for

Hearing instrument specialists can test for the sole purpose of fitting a hearing aid per

determine scope of practice CPT codes (procedures/services) must be ones typically performed

(diagnoses) code(s) CPT codes selected must be apparent to an insurance company as to why test

are 4 HCPCS codes, 3 of them for screening Claim Form Current Procedural Terminology (CPT) AND

you performed (CPT) Diagnosis results (ICD) Resulting recommendations if product (HCPCS) Ties

4 Where to Purchase? SlidesCarnival icons are editable shapes. AMA bookstore: navaction=jump Optum 360: ppcid=optum%20code%20books&pstc= Amazon: n%3a283155%2cn%3a227568%2ck%3acpt+code+book&keyword s=cpt+code+book&ie=utf8&qid= &rnid=1000 Thoughts: Considerations: Case-building for differential diagnosis Provides value in the healthcare system Fiscal recognition for services Hearing instrument specialists can test for the sole purpose of fitting a hearing aid per state licensure Perform only those procedures recognized by your state licensure law They determine scope of practice CPT codes (procedures/services) must be ones typically performed by audiologists or speech-language pathologists (SLPs) CPT codes must support the chosen ICD (diagnoses) code(s) CPT codes selected must be apparent to an insurance company as to why test was performed Hearing aid claims will predominantly utilize the HCPCS codes For SLPs, there are 4 HCPCS codes, 3 of them for screening Claim Form Current Procedural Terminology (CPT) AND International Classification of Diseases (ICD) Lists the CPT(s), ICD(s) and HCPCS codes: What you performed (CPT) Diagnosis results (ICD) Resulting recommendations if product (HCPCS) Ties the coding systems together Have to support each other It needs to be apparent that what you performed would result in the disease code chosen What is being billed has to be appropriate to what you are licensed to perform Documentation has to reflect the above points 4

5 Coding Mantra: Coding Mantra (cont.) Code for the reason for the visit (Medicare transmittal) Code with signs and/or symptoms Why the patient presented to your office Code by patient complaints (medical necessity) Tinnitus? Hearing loss? Disequilibrium? Code by outcome of the procedure results SNHL? Tinnitus? Conductive hearing loss, middle ear? Must code for what you did and what it indicates CODING IS NOT TO BE DRIVEN BY REIMBURSEMENT CPT codes CPT Codes Utilized by Audiologists: Basic comprehensive audiometry Was the only audiology bundled code until 1/1/10: (Pure tone air and bone conduction audiometry) (SRT) and (WRS) 3 bundled codes: CPT Vestibular (92541, 92542, 92544, 92545) CPT Tympanometry, ART (92567 and 92568) CPT Tympanometry, ART, ARD (92567, 92568, 92569) CPT TM five-digit codes, descriptions, and other data only are copyright 2016 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. TM CPT TM is a trademark of the American Medical Association Spontaneous nystagmus, including gaze Positional nystagmus test Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests) Optokinetic nystagmus test Because these do not include with recording, Medicare will not recognize them. CPT codes (cont.) CPT Codes (cont.) Caloric vestibular test with recording, bilateral; bithermal (ie, one warm and one cool irrigation in each ear for a total of four irrigations) Monothermal, (ie, one irrigation in each ear for a total of two irrigations) Same temperature in both ears Basic vestibular evaluation Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording Positional nystagmus test, minimum of 4 positions, with recording Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording Oscillating tracking test, with recording Sinusoidal vertical axis rotational testing Use of vertical electrodes (list separately in addition to code for primary procedure) Computerized dynamic posturography 5

6 CPT Codes (cont.) CPT Codes (cont.) Tympanometry and reflex thresh measurements Screening test, pure tone, air only Pure tone audiometry (threshold), air only Pure tone audiometry (threshold); air and bone Speech audiometry threshold Speech audiometry threshold, with speech recognition Comprehensive audiometry threshold evaluation and speech recognition (92553 and combined) Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis Audiometric testing of groups Bekesy audiometry, screening Bekesy audiometry, diagnostic Loudness balance test, alternate binaural or monaural CPT Codes (cont.) CPT Codes (cont.) Tone decay test Short increment sensitivity index (SISI) Stenger test, pure tone Tympanometry (impedance testing) Acoustic reflex testing, threshold Acoustic immittance testing Filtered speech test Staggered spondaic word test Sensorineural acuity level test Synthetic sentence identification test Stenger test, speech Visual reinforcement audiometry (VRA) Conditioned play audiometry (CPA) CPT codes (cont.) CPT Codes (cont.) Select picture audiometry Electrocochleography (NRT) Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system, comprehensive Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system, limited Distortion product evoked otoacoustic emissions, limited evaluation (to confirm the presence or absence of hearing disorder, 3 6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report Distortion product evoked otoacoustic emissions, comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report 6

7 CPT codes (cont.) CPT Codes (cont.) Hearing aid examination and selection, monaural Hearing aid examination and selection, binaural Hearing aid check, monaural Hearing aid check, binaural Electroacoustic evaluation for hearing aid, monaural Electroacoustic evaluation for hearing aid, binaural Ear protector attenuation measurements Diagnostic analysis of cochlear implant, patient under 7 years of age; with programming Diagnostic analysis of cochlear implant, patient under 7 years of age; subsequent reprogramming CPT Codes (cont.) CPT Codes (cont.) Diagnostic analysis of cochlear implant, age 7 years or older with programming Diagnostic analysis of cochlear implant, age 7 years or older with reprogramming Evaluation of central auditory function, with report; initial 60 minutes Evaluation of central auditory function, with report; each additional 15 minutes Assessment of tinnitus (includes pitch, loudness matching, and masking) Assessment of auditory rehabilitation status; first hour each additional 15 minutes Auditory rehabilitation; prelingual hearing loss Auditory rehabilitation; postlingual hearing loss CPT Codes (cont.) CPT Codes (cont.)-an aside Diagnostic analysis with programming of auditory brainstem implant, per hour Unlisted otorhinolaryngological service or procedure For those procedures that do not have dedicated codes Likely will be denied, need to submit documentation for: What you did Why you did it What you learned from it that impacted that patient s diagnosis and treatment VEMPs ASSRs Saccades Head shake Tinnitus Removal of non-impacted cerumen Eustachian Tube dysfunction Frenzel goggles CPT and (AMA s CPT Assistant, July 2014) Evaluation of auditory rehabilitation status, first hour/each additional 15 minutes Utilize when evaluating patient s function prior or post fitting of unilateral or bilateral (and to identify acoustic characteristics of sounds): Hearing aids (don t bill to Medicare) Osseo-integrated devices Cochlear implants Brainstem implants Confirm with payer must be for procedures greater than 31 minutes Document start and end time in chart with time based codes 7

8 CPT Codes (cont.) CPT Codes (cont.) Vestibular codes: CPT , Audiologic procedures: CPT Evoked potential codes: CPT OAE codes: CPT 92558, Hearing aid related codes: CPT Cochlear implant codes: CPT Central auditory test codes: CPT Tinnitus code: CPT CPT Codes (cont.) Modifiers (cont.) Audiologic (aural) (re)habilitation CPT code Nameless codes ----unlisted otorhinolaryngological service or procedure CPT VEMPs (per AMA s CPT Assistant, March 2011) Saccades with recording (per CPT Assistant September 2015) Requires documentation to be submitted attesting to why additional time and/or work was necessary An audit and/or a delay in payment may occur Modifiers Modifiers (cont.) -22 Unusual Procedural Services Utilized when procedure is greater than what is typically required Involves increase in provider work, time and complexity of what is typically performed Many insurance carriers state that if it is less than 25% more work, should not append May yield a 20-50% increase of the allowable rate Example: Professional component Utilized with: ENG (CPT , 92458) ABR (CPT 92585) OAE (CPT 92587, 92588) Utilized: When another professional performed the procedure You do the interpretation and prepare the report Example:

9 Modifiers (cont.) Technician Services TC Technical component Utilized with: ENG (CPT , 92548) ABR (CPT 92585) OAE (CPT 92587, 92588) Utilized: When you only performed the test Bill TC Another provider does the interpretation They bill 26 This equals the same reimbursement as the global fee Example: TC TC may be performed by a technician under a physician s supervision May need to demonstrate tech s qualifications Must be filed by a physician who provided direct supervision (must be in the facility and available) TC services can not be filed by an audiologist when performed by another provider, including an audiologist Modifiers (cont.) Modifiers (cont.) -33 Preventative Service Use with newborn hearing screening code(s) (OAE screening) (ABR screening) No co-pay or deductible is to be applied -52 Reduced services Procedure is partially reduced or eliminated Discontinued at provider s discretion after the procedure commenced Can be used to indicate monaural vs binaural testing Not recognized by all carriers Example: Modifiers (cont.) Modifiers (cont.) -53 Discontinued procedure Procedure started, patient s well being becomes jeopardized during the procedure, provider discontinues Example: Patient having ototoxicity monitoring, becomes ill during procedure Reimbursed at 25% of the allowed amount Example: Distinct procedural service Will need to append to CPT codes 92541, 92542, or ONLY if performing 1-3 tests of the 4 code bundle Documentation should include why you performed the tests you did 9

meet the definition of any Medicare benefit Often used when a secondary insurance has a hearing aid benefit On the Office of the Inspector General s list for 2009 GA-Waiver of liability on file To be

excluded GZ- Must 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

ed by the beneficiary. Evaluation and Manage

,triwest, Aetna) do not recognize audiologists for E/M codes; don t bill the same date with an ENT service Ensure that your state licensure laws allow E/M codes Do NOT file to Medicare Time,

10 Modifiers (cont.) Medicare Modifiers -76 Procedure was performed more than one time on the same date of service Glycerol or urea test Ototoxicity monitoring GY-Item or service is statutorily excluded or does not meet the definition of any Medicare benefit Often used when a secondary insurance has a hearing aid benefit On the Office of the Inspector General s list for 2009 GA-Waiver of liability on file To be used when a denial is expected and an ABN is on file No ABN, no billing the patient GX- Notice of Liability Issued, Voluntary Under Payer Policy For services that are non-covered, statutorily excluded GZ- Must 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 Advance Beneficiary Notification (ABN) signed by the beneficiary. Evaluation and Management Codes (E/M) E/M Medicare and commercial payors (e.g.,triwest, Aetna) do not recognize audiologists for E/M codes; don t bill the same date with an ENT service Ensure that your state licensure laws allow E/M codes Do NOT file to Medicare Time, complexity and review of systems are required Document, include start and end times for diagnostic procedures only Personal thought: would not code beyond a level 2 so as not to trigger an audit Bill all payers and patients if you bill anyone for E/M codes Read the CPT codebook s first section for information Read CMS Medlearn Guide to E/M codes Learning-Network-MLN/MLNProducts/Downloads/eval_ mgmt_serv_guide-icn pdf New and established patient codes New: CPT Established: CPT If patient has been seen in your practice in the last 3 years Need to include Review of Systems (ROS): ROS (cont.) Head, including the face Neck Chest, including breasts and axilla Abdomen Genitalia, groin, buttocks Back Each extremity Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hemotologic/lymphatic/immunologic 10

11 E/M Codes E/M Codes (cont.) CPT A problem focused history A problem focused examination Straightforward medical decision making Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs CPT An expanded problem focused history An expanded problem focused examination Straightforward medical decision making Problems are of low-moderate severity Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs Physicians typically spend 10 minutes face-to-face with the patient and/or family Physicians typically spend 20 minutes face-to-face with the patient and/or family E/M Codes (cont.) E/M Codes (cont.) CPT A detailed history A detailed examination Medical decision making of low complexity Problems are of moderate severity Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs Physicians typically spend 30 minutes face-to-face with the patient and/or family CPT A comprehensive history A comprehensive examination Medical decision making of moderate complexity Problems are of moderate to high severity Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs Physicians typically spend 45 minutes face-to-face with the patient and/or family E/M Codes (cont.) E/M Codes (cont.) CPT A comprehensive history A comprehensive examination Medical decision making of high complexity Problems are of moderate to high severity Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs Physicians typically spend 60 minutes face-to-face with the patient and/or family CPT code May not require a physician s presence Minimal problem Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs Typical time spent: 5 minutes 11

12 E/M Codes (cont.) E/M Codes (cont.) CPT code A problem focused history A problem focused examination Straightforward medical decision making Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs Problems are minor Physicians typically spend 10 minutes face-to-face with the patient and/or family CPT code An expanded problem focused history An expanded problem focused examination Problems are of low to moderate severity Medical decision making of low complexity Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs Physicians typically spend 15 minutes face-to-face with the patient and/or family E/M Codes (cont.) E/M Codes (cont.) CPT code A detailed history A detailed examination Medical decision making of moderate complexity Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs Physicians typically spend 25 minutes face-to-face with the patient and/or family CPT Code A comprehensive history A comprehensive examination Medical decision making of high complexity Problems are of moderate to high severity Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs Physicians spend 40 minutes face-to-face with the patient and/or family Cerumen Management Cerumen Impaction Is in the scope of practice of audiology Unless cerumen is impacted, should not be billing for it separately July 2002, CPT Assistant defines impaction Defined by the American Medical Association publication CPT Assistant (CPT Assistant, July 2005) must meet one or more of the following conditions to be considered impacted : Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition; Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc.; Associated with foul odor, infection or dermatitis; Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations 12

13 CPT Assistant (cont.) Cerumen Management Codes The CPT Assistant article further states removing wax that is not impacted does not warrant the reporting of CPT code [Removal of impacted cerumen (separate procedure), 1 or both ears]. Documentation of cerumen removal should include the time, effort, method(s) and equipment to provide the service Removal of impacted cerumen requires visualization with an otoscope, head loupes, or operating microscope and the use of specialized tools such as curettes, forceps, lavage, and/or suction for proper removal NEW for 2016: Removal impacted cerumen using irrigation/lavage, unilateral Removal impacted cerumen requiring instrumentation, unilateral Impaction defined as cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition and obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills. If bilateral, use -50 modifier OR -AMA CPT Assistant, January 2016 Cerumen Management (cont.) Speech-Language Pathology CPT codes Check with state licensure laws Some state licensure laws do not allow CM to be performed by an audiologist Removal restrictions may apply Can offer a voluntary ABN Any patient can pay for cerumen removal by an audiologist, if allowed by state licensure law Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy (RWUw 2.26) Swallowing function, with cineradiography/videoradiography (0.53) Speech-Language Pathology CPT Codes (cont.) Speech-Language Pathology CPT Codes (cont.) Treatment of speech, language, voice, communication, and/or auditory processing disorder, individual (RVUw 1.30) (Do not report in conjunction with 0364T, 0365T, 0368T, 0369T) group, 2 or more individuals (RVUw 0.33) (Do not report in conjunction with 0366T, 0367T, 0372T) (For auditory rehabilitation, prelingual hearing loss, use 92630) (For auditory rehabilitation, postlingual hearing loss, use 92633) (For cochlear implant programming, see ) Nasopharyngoscopy with endoscope (separate procedure) (RVUw.61) Both may be filed by an independent SLP without supervision unless supervision is a requirement of state law(s) or Medicare Administrative Contractor Manderly Cohen and Michael Setzen, The Essential Guide to Coding in Otolaryngology: Coding, Billing, and Practice Management (2016) 13

14 Speech-Language Pathology Codes (cont.) Speech-Pathology Codes (cont.) Laryngeal function studies (i.e.,aerodynamic testing and acoustic testing) (RVUw.75) Use -52 modifier if only aerodynamic testing only or acoustic testing only Evaluation of speech fluency (e.g., stuttering, cluttering) (1.75) Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) (1.50) with evaluation of language comprehension and expression (e.g., receptive and expressive language) (3.00) Non-speech generating services are bundled and billed with this code -52 modifier for language only Behavioral and qualitative analysis of voice and resonance (1.50) Treatment of swallowing dysfunction and/or oral function for feeding (no group therapy code for dysphagia, but Medicare may accept 92508) (RVUw 1.40/RVUw for (.33) Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech Under Medicare, applies to tracheoesophageal prostheses, voice amplifiers and artificial larynges (1.26) Evaluation for prescription of non-speech generating augmentative and alternative communication device, face-to-face with the patient, first hour (1.75) each additional 30 minutes (list separately in addition to primary procedure) (0.65) Therapeutic service(s) for use of non-speech generating device, including programming and modification (1.40) Evaluation for prescription for speech generating augmentative and alternative communication device, face-to-face with the patient, first hour (1.85) each additional 30 minutes (list separately in addition to code for primary procedure) (0.70) Therapeutic services for the use of speech-generating device, including programming and modification (1.50) Speech-Language Pathology Codes (cont.) Speech-Language Pathology Codes (cont.) Evaluation of oral and pharyngeal swallowing function (RVUw 1.30) Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording; (1.27) Use if performed without cine or video recording interpretation and report only (0.71) Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording (1.27) interpretation and report only (0.63) Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording; (RVUw 1.88) interpretation and report only (0.79) Evaluation of auditory rehabilitation status, first hour (1.40) each additional 15 minutes (.33) Auditory rehabilitation; pre-lingual hearing loss(0.00) Auditory rehabilitation; post-lingual hearing loss (0.00) Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour (1.75) Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument (0.00) Developmental testing (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments) with interpretation and report (2.6) Standardized cognitive performance testing (eg, Ross Information Processing Assessment) per hour of a qualified health care professional s time, both face-to-face administrating tests to the patient and time interpreting these test results and preparing the report (1.70) Speech-Language Pathology Codes (cont.) Time based SLP CPT Codes Therapeutic procedure(s), group (2 or more individuals) (.29) Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-toone) patient contact, each 15 minutes (0.44) Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-to-one) patient contact, each 15 minutes (0.44) Unlisted otorhinolaryngological service or procedure (0.00) 92605, (non-speech device) 92607, (speech-generating device) 92626, (aural rehabilitation) (aphasia) 96125, (cognitive) (sensory) Can bill 1 hour if 31 minutes or more were spent with patient For and 97533, minimum time is 8 minutes for a 15 minute code in order to file the claim V5336 Repair/Modification of AAC device (excluding adaptive hearing aid) 14

15 Just a few more And Online assessment and management service provided by a qualified nonphysician health care professional to an established patient or guardian, not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network (0.00) Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more; participation by nonphysician qualified health care professional (0.82) Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health care professional (0.72) Otoscopy, removal of non-impacted cerumen and anterior rhinoscopy are included in the E/M service. SLP modifiers Healthcare Common Procedure Coding System (HCPCS) Codes -22 Increased Procedural Services -52 Reduced Services -59 Distinct Procedural Service Use with edits for 2 procedures not typically performed on the same day by the same provider, but may be appropriate to perform on the same date of service Includes but is not limited to: (laryngeal videostroboscopy)/92520 (laryngeal function studies) (dysphagia therapy)/92520(laryngeal function studies) (individual therapy)/92508 (group therapy) GN (Medicare) to indicate therapy service was performed by an SLP Addresses what CPT did not with: Some services V5010 (Assessment for hearing aid) V5020 (Conformity evaluation) S0618 (Audiometry for hearing aid evaluation to determine the level and degree of hearing loss) Supplies: Hearing aids Dispensing Earmold (and earmold impression) Batteries Assistive Listening Devices HCPCS Codes (Procedures) HCPCS Codes (cont.) V5010 Assessment for hearing aid V5011 Fitting/orientation/checking of hearing aid V5014 Repair/modification of hearing aid V5020 Conformity evaluation V5030 Hearing aid, monaural, body worn, air conduction V5040 Hearing aid, monaural, body worn, bone conduction V5050 Hearing aid, monaural, in the ear V5060 Hearing aid, monaural, behind the ear V5070 Glasses, air conduction V5080 Glasses, bone conduction 15

16 HCPCS Codes (cont.) HCPCS Codes (cont.) V5090 Dispensing fee, unspecified hearing aid V5095 Semi-implantable middle ear hearing prosthesis V5100 Hearing aid, bilateral, body worn V5110 Dispensing fee, bilateral V5120 Binaural, body V5130 Binaural, in the ear V5140 Binaural, behind the ear V5150 Binaural, glasses V5160 Dispensing fee, binaural V5170 Hearing aid, CROS, in the ear V5180 Hearing aid, CROS, behind the ear V5190 Hearing aid, CROS, glasses V5200 Dispensing fee, CROS V5210 Hearing aid, BICROS, in the ear V5220 Hearing aid, BICROS, behind the ear V5230 Hearing aid, BICROS, glasses V5240 Dispensing fee, BICROS HCPCS Codes (cont.) HCPCS Codes (cont.) V5241 Dispensing fee, monaural hearing aid, any type V5242 Hearing aid, analog, monaural, CIC V5243 Hearing aid, analog, monaural, ITC V5244 Hearing aid, digitally programmable analog, monaural, CIC V5245 Hearing aid, digitally programmable, analog, monaural, ITC V5246 Hearing aid, digitally programmable, analog, monaural, ITE V5247 Hearing aid, digitally programmable, analog, monaural, BTE HCPCS Codes (cont.) HCPCS Codes (cont.) V5248 Hearing aid, analog, binaural, CIC V5249 Hearing aid, analog, binaural, ITC V5250 Hearing aid, digitally programmable analog, binaural, CIC V5251 Hearing aid, digitally programmable analog, binaural, ITC V5252 Hearing aid, digitally programmable, binaural, ITE V5253 Hearing aid, digitally programmable, binaural, BTE V5254 Hearing aid, digital, monaural, CIC V5255 Hearing aid, digital, monaural, ITC V5256 Hearing aid, digital, monaural, ITE V5257 Hearing aid, digital, monaural, BTE 16

17 HCPCS Codes (cont.) HCPCS Codes (cont.) V5258 Hearing aid, digital, binaural, CIC V5259 Hearing aid, digital, binaural, ITC V5260 Hearing aid, digital, binaural, ITE V5261 Hearing aid, digital, binaural, BTE V5262 Hearing aid, disposable, any type, monaural V5263 Hearing aid, disposable, any type, binaural V5264 Earmold/insert, not disposable, any type V5265 Earmold/insert, disposable, any type HCPCS Codes (cont.) HCPCS Codes (cont.) V5266 Battery for use in hearing device V5267 Hearing aid or ALD supplies/accessories, not otherwise specified V5268 Assistive listening device, telephone amplifier, any type V5269 Assistive listening device, alerting, any type V5270 Assistive listening device, television amplifier, any type V5271 Assistive listening device, television caption decoder V5272 Assistive listening device, TDD V5273 Assistive listening device, for use with cochlear implant V5274 Assistive listening device, not otherwise specified V5275 Ear impression, each HCPCS Codes (cont.) V5281 Assistive listening device, personal fm/dm system, monaural, (1 receiver, transmitter, microphone), any type V5282 ALD, personal fm/dm system, binaural (2 receivers, transmitter, microphone), any type V5283 ALD, personal fm/dm neck, loop induction receiver V5284 ALD, personal fm/dm, ear level receiver HCPCS Codes (cont.) V5285 ALD, personal fm/dm, direct audio input receiver V5286 ALD, personal blue tooth fm/dm receiver V5287 ALD, personal fm/dm receiver, not otherwise specified V5288 ALD, personal fm/dm transmitter ALD 17

18 HCPCS Codes (cont.) Hearing Aid Modifiers V5289 ALD, personal fm/dm adapter/boot coupling device for receiver, any type V5290 ALD, transmitter microphone, any type V5298 Hearing aid, not otherwise classified V5299 Hearing service, miscellaneous May be payer dependent RT indicates right side (ear) LT indicates left side (ear) May need to bill monaural codes with modifier for each ear separately instead of binaural codes Speech-Language Pathology Codes HCPCS: V5336 Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid) V5362 Speech screening* V5363 Language screening* V5364 Dysphagia screening* Break! *Screenings are not recognized by Medicare and subsequently, may be not be recognized by commercial payers Differences between ICD-9 and ICD-10 ICD-10-CM Tripled+ number of codes 76% address laterality Alphanumeric and numeric Code length up to 7 characters Most audiology codes are still 5 spaces Decimal is in the same place 7 th digit indicates initial, long term follow up and subsequent encounter should be used for T codes (poisoning section) 18

rather than by the diagnosis or the patient s condition (CMS, Chapter 15, page 101) and/or Signs and symptoms and/or The outcome of the test results Documentation

mor bid i ty (kō-mōr-bid'i-tē) 1. A concomitant but unrelated pathologic or disease process. 2. EPIDEMIOLOGY Coexistence of two or more disease processes.

com/comorbidity Diabetes Falls/dizziness Depression It s not just about hearing loss or balance! Or Speech! Or Swallowing!

19 Differences (cont.) In addition Continue to code for: Coverage and, therefore, payment for audiological diagnostic tests is determined by the reason the tests were performed, rather than by the diagnosis or the patient s condition (CMS, Chapter 15, page 101) and/or Signs and symptoms and/or The outcome of the test results Documentation must address this and correspond to the code chosen Must make sense in a chart review or audit Code for co-morbidities as long as addressed in your chart notes co mor bid i ty (kō-mōr-bid'i-tē) 1. A concomitant but unrelated pathologic or disease process. 2. EPIDEMIOLOGY Coexistence of two or more disease processes. [co- + L. morbidus, diseased] Diabetes Falls/dizziness Depression It s not just about hearing loss or balance! Or Speech! Or Swallowing! Basics of ICD-10 s Laterality Adds to the volume of the number of codes (76%) There are a few exceptions to the rules Bilateral codes end in 3 Exceptions: Bilateral CHL (H90.0) Bilateral Mixed (H90.6) SlidesCarnival icons are editable shapes. Legend for this map 1 st digit is alphanumeric For audiologists, predominantly will be F, H, Q, R, T, and/or Z For speech-language pathologists will be F, R, and I SlidesCarnival icons are editable shapes. 19

always a decimal after the first three digits, like ICD 9 s First 3 digits define the code category Second three digits etiology, anatomical site, or severity 4 6 digits may be letters or numbers, or

Used predominantly by audiologists for those codes beginning with T.

20 ICD-10 Composition ICD-10 s (cont.) Organized in 21 chapters Each chapter is uniquely identified by letter Letter does not indicate content 1 st digit always alphabetic (HL is H90 H95) 2 nd and 3 rd digits always numeric There is always a decimal after the first three digits, like ICD 9 s First 3 digits define the code category Second three digits etiology, anatomical site, or severity 4 6 digits may be letters or numbers, or may be a placeholder (x) 4 th etiology 5 th body part 6 th severity Seventh digit extension describes the encounter type (initial, subsequent, sequela). Used predominantly by audiologists for those codes beginning with T. A is initial encounter (active treatment) D is subsequent encounter (post active tx, routine care) S is sequela for complications or conditions that arise from a direct result of a condition not specifically under treatment Ototoxicity monitoring A dash (-) indicates additional specificity in the 5 th and 6 th digit positions (H91.0-) x indicates a placeholder Used as a 5 th character placeholder for certain 6 digit codes Rules Hearing loss codes begin with H Not for hearing It is Chapter 8, Diseases of the Ear and Mastoid Process of 21 chapters You ll need other codes for certain situations or processes There s plenty of room on the CMS 1500 claim form 12 lines instead of 4 May need 7 th character, code dependent Rules (cont.) Sample Codes-CHL Be aware of the codes in other chapters: F: Mental, Behavioral and Neurodevelopmental Disorders I: Sequelae of Cerebrovascular Disease Q: Congenital Malformations, Deformations and Chromosomal Abnormalities R: Symptoms, Signs and Abnormal Clinical and Laboratory Findings T: Injury, Poisoning, and Certain Other Consequences of External Causes Z: Factors Influencing Health Status and Contact with Health Services H90.0 Bilateral conductive hearing loss H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side CHL right ear, no hearing loss in the left H90.12 Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side CHL left ear, no hearing loss in the right 20

21 Sample Codes-SNHL Changes H90.3 Sensorineural hearing loss, bilateral H90.41 Sensorineural unilateral hearing loss with unrestricted hearing on opposite side, right ear SNHL right ear, no hearing loss left ear H90.42 Sensorineural unilateral hearing loss with unrestricted hearing on opposite side, left ear SNHL left ear, no hearing loss right ear More specific tinnitus codes (objective, subjective) are non-existent Conductive HL codes are no longer specified as to anatomy H90.0x SNHL are no longer categorized as sensory nor neural H90.3 is SNHL Additions NOS/NEC Laterality is addressed with code indicator Threshold shift codes H Ototoxicity code H91.0- H91.3 Ototoxic HL, bilateral T36.5X5 Adverse effects of aminoglycosides Intra-operative and post procedural complications H95 Not otherwise specified (NOS). Should be avoided. Codes titled unspecified are for use when the information in the medical record is insufficient to assign a more specific code. Not elsewhere classified (NEC). Codes titled other or other specified are for use when the information in the medical record provides detail for which a specific code does not exist. These represent specific disease entities for which no specific code exists so the term is included within an other code. Coding and Laterality Code Sections 1 = Right 2 = Left 3 = Bilateral 0 or 9 = Unspecified EXCEPTIONS: H90.0 Conductive HL, bilateral H90.6 MHL, bilateral H60-H62: Diseases of external ear Includes acquired deformity of pinna, stenosis, exostoses, cerumen, and hematomas H65-H75: Diseases of middle ear and mastoid Includes Eustachian Tube disorders, perforations H80-H83: Diseases of inner ear Includes otosclerosis, vestibular/balance disorders, and noise effects (HL) H90-H95: Other disorders of ear Includes otalgia, otorrhea, deafness, hearing loss, transient ischemic deafness, tinnitus, recruitment, diplacusis, hyperacusis, temporary threshold shift, neuritis, intraoperative and postprocedural complications of ear and mastoid, NEC 21

22 Diseases of Inner Ear (H80-H83) ICD-10 codes (not an exhaustive list) Diseases of inner ear: H80-H83 (H80) Otosclerosis (H81) Disorders of vestibular function (H81.0) Ménière's disease (H81.1) Benign paroxysmal vertigo (H81.2) Vestibular neuronitis (H81.3) Other peripheral vertigo (H81.4) Vertigo of central origin Central positional nystagmus (H82) Vertiginous syndromes in diseases classified elsewhere (H83) Other diseases of inner ear (H83.0) Labyrinthitis (H83.1) Labyrinthine fistula (H83.2) Labyrinthine dysfunction (H83.3) Noise effects on inner ear H81 Disorders of vestibular function Excludes: vertigo: NOS (R42), epidemic (A88.1) H81.0 Ménière s disease Labyrinthine hydrops Ménière s syndrome or vertigo H81.1 Benign Paroxysmal vertigo H81.2 Vestibular neuronitis H81.3 Other peripheral vertigo Lermoyez syndrome Vertigo: Aural Otogenic Peripheral NOS (not otherwise specified) ICD-10 codes (cont.) ICD-10 codes (cont.) H81.4 Vertigo of central origin Central positional nystagmus H81.8 Other disorders of vestibular function H81.9 Disorder of vestibular function, unspecified Vertiginous syndrome NOS H82 Vertiginous syndromes in diseases classified elsewhere H83 Other diseases of inner ear H83.0 Labyrinthitis H83.1 Labyrinthine fistula H83.2 Labyrinthine dysfunction Hypersensitivity Hypofunction } of labyrinth Loss of function ICD-10 codes (cont.) ICD-10 codes (cont.) Other disorders of ear (H90-H95) H83.3 Noise effects on inner ear Acoustic trauma Noise-induced hearing loss H83.8 Other specified diseases of inner ear H83.9 Disease of inner ear, unspecified H90 Conductive and sensorineural hearing loss Includes: congenital deafness Excludes: deaf mutism NEC (H91.3) (not elsewhere classified) deafness NOS (H91.9) hearing loss: NOS (H91.9) Noise-induced (H83.3) Ototoxic (H91.0) Sudden (idiopathic) (H91.2) 22

23 ICD-10 Codes-CHL New ICD-10-CM codes-10/1/16 H90.0 Bilateral conductive hearing loss H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side CHL right ear, no hearing loss in the left H90.12 Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side CHL left ear, no hearing loss in the right H90.2 CHL, unspecified H90.A11 Conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side H90.A12 Conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side ICD-10 Codes-SNHL New ICD-10-CM Codes (cont.) H90.3 Sensorineural hearing loss, bilateral H90.41 SNHL, unilateral, right ear, with unrestricted hearing on contralateral side H90.42 SNHL, unilateral, left ear, with unrestricted hearing on contralateral side H90.A21 Sensorineural hearing loss, unilateral, right ear, with restricted hearing on the contralateral side H90.A22 Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the contralateral side ICD-10 codes (cont.) ICD-10 Codes-Mixed HL H90.5 Sensorineural hearing loss, unspecified Congenital deafness NOS Hearing loss: Central Neural } NOS Perceptive Sensory Sensorineural deafness NOS H90.6 Mixed conductive and SNHL, bilateral H90.7 Mixed CHL and SNHL, unilateral with unrestricted hearing on the contralateral side H90.71 Mixed CHL and SNHL, unilateral, right ear, with unrestricted hearing on the contralateral side H90.72 Mixed CHL and SNHL, unilateral, left ear, with unrestricted hearing on the contralateral side H90.8 Mixed CHL and SNHL, unspecified 23

24 New ICD-10-CM Codes (cont.) ICD-10 codes (cont.) H90.A31 Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side H90.A32 Mixed conductive and sensorineural hearing, unilateral, left ear with restricted hearing on the contralateral side H91 Other hearing loss Excludes: abnormal auditory perception (H93.2) hearing loss as classified in H90.- impacted cerumen (H61.2) noise-induced hearing loss (H83.3) psychogenic deafness (F44.6) transient ischaemic deafness (H93.0) H91.0 Ototoxic hearing loss Use additional external cause code, if desired, to identify toxic agent. ICD-10 codes (cont.) ICD-10 (cont.) H91.8 Other specified HL H91.8X Other specified HL H91.8X1 Other specified HL, right ear H91.8X2 Other specified HL, left ear H91.8X3 Other specified HL, bilateral H91.8X9 Other specified HL, unspecified ear Can use these for different ears, different types of hearing loss H91.9 Hearing loss, unspecified Deafness: NOS High frequency Low frequency H92 Otalgia and effusion of ear ICD-10 codes (cont.) ICD-10 Code -Tinnitus H93 Other disorders of ear, not elsewhere classified H93.0 Degenerative and vascular disorders of ear Transient ischaemic deafness H93.1 Tinnitus H93.11 Tinnitus, right ear H93.12 Tinnitus, left ear H93.13 Tinnitus, bilateral H93.19 Tinnitus, unspecified ear 24

25 New ICD-10-CM Codes (cont.) ICD-10 codes (cont.) H93.A Pulsatile tinnitus H93.A1 Pulsatile tinnitus, right ear H93.A2 Pulsatile tinnitus, left ear H93.A3 Pulsatile tinnitus, bilateral H93.A9 Pulsatile tinnitus, unspecified ear Z0.58 Observation and evaluation of newborn for other specified suspected condition ruled out H93.2 Other abnormal auditory perceptions Auditory recruitment Diplacusis Hyperacusis Temporary auditory threshold shift Excludes: auditory hallucinations (R44.0) (H93.2-H93.299) ICD-10 Codes (cont.) F: Mental, Behavioral and Neurodevelopmental Disorders H93.3 Disorders of acoustic nerve Disorder of 8 th cranial nerve H93.8 Other specified disorders of ear H93.9 Disorder of ear, unspecified F01-F03.91 Dementia F04-F19.99 Amnesia; other mental, personality and mood disorders; alcohol, opiod, cannabis, sedatives, cocaine, other stimulants, hallucinogens, nicotine, inhalants, other psychoactives use/abuse F20-F48.9 Schizophrenia, manic episodes, bipolar disorder, major depressive disorder, phobic, panic, obsessivecompulsive, PTSD, dissociative/conversion, hypochondriacal, non-psychotic, and other anxiety disorders F50-F59 Eating/sleeping/sexual disorders, behavior syndromes associated with non-psychoactive substance abuse F60-69 Disorders of adult personality and behavior F70-F79 Intellectual disabilities F80-F89 Pervasive and specific developmental disorders F80.0-F80.2 Phonological, expressive, mixed receptive-expressive disorder F80.4 speech delay due to hearing loss (code also type of HL) F80.8-F89 Other developmental disorders of speech and language, scholastic skills F90-F98.9 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence F99 Mental disorder, NOS Q: Congenital malformations, deformations and Chromosomal Abnormalities R: Symptoms, Signs and Abnormal Clinical and Laboratory Findings Q16 Congenital malformations of ear causing impairment of hearing Q16.0 Congenital absence of (ear) auricle Q16.1 Congenital absence, atresia and stricture of auditory can (external) Q16.3 Congenital malformation of ear ossicles Q16.4 Other congenital malformations of middle ear Q16.9 Congenital malformation of ear causing impairment of hearing, unspecified Q17.1 Macrotia Q17.4 Misplaced ear (low-set ears) The codebook states the R chapter includes signs, symptoms, abnormal results and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded. May need to use when there is no H code R42, dizziness and giddiness, is a great example R62.0 delayed milestones in childhood 25

26 Auditory Symptoms R42 Dizziness and giddiness Light headedness Vertigo NOS Excludes vertiginous syndromes (H81. ) R62.0 Delayed milestones in childhood R94.12 Abnormal results of function studies of ear and other special senses R Abnormal auditory function study R Abnormal vestibular function study R Abnormal results of other function studies of ear and other special senses T: Injury, Poisoning, and Certain Other Consequences of External Causes Includes barotrauma, foreign bodies, burns, frostbite, medications, gases, solvents, heavy metals, snake venom, etc. Potential for ototoxicity utilization Includes complications with devices T Codes T Codes (cont.) T36.3 Poisoning by, adverse effect of and underdosing of macrolides T36.3X Poisoning by, adverse effect of and underdosing of macrolides T36.3X5 Adverse effects of macrolides T36.5 Poisoning by, adverse effect of and underdosing of aminoglycosides T36.5X Poisoning by, adverse effect of and underdosing of aminoglycosides T36.5X4 Poisoning by aminoglycosides, undetermined T36.5X5 Adverse effect of aminoglycosides T39.0 Poisoning by, adverse effect of and underdosing of salicylates T39.01 Poisoning by, adverse effect of and underdosing of aspirin T Adverse effect of aspirin T39.09 Poisoning by, adverse effect of and underdosing of other salicylates T Adverse effect of salicylates T Codes (cont.) T Codes (cont.) T39.3 Poisoning by, adverse effect of and underdosing of other non-steroidal anti-inflammatory drugs (NSAID) T39.31 Poisoning by, adverse effect of and underdosing of propionic acid derivatives (includes fenoprofen, flurbiprofen, ibuprofen, ketoprofen, naproxen oxaprozin) T Adverse effect of proprionic acid derivatives T39.39 Poisoning by, adverse effect of and underdosing of other non-steroidal anti-inflammatory drugs (NSAID) T Adverse effect of other non-steroidal anti-inflammatory drugs (NSAID) T40.3 Poisoning by, adverse effect of and underdosing of methadone T40.3X Poisoning by, adverse effect of and underdosing of methadone T40.3X5 Adverse effect of methadone T45.1 Poisoning by, adverse effect of and underdosing of antineoplastic and immunosuppressive drugs T45.1X Poisoning by, adverse effect of and underdosing of antineoplastic and immunosuppressive drugs T45.1X5 Adverse effect of anti-neoplastic and immunosuppressive drugs T46.7X5 Adverse effect of peripheral vasolidators T50.1X Poisoning by, adverse effect of and underdosing of loop (high ceiling) diuretics T50.1X5 Adverse effect of loop (high ceiling) diuretics 26

27 T Codes (cont.) T codes (cont.) T52 Toxic effect or organic solvents T52.1 Toxic effect of benzene T52.1X Toxic effects of benzene T52.1X1 Toxic effect of benzene, accidental (unintentional) T52.1X2 Toxic effect of benzene, intentional self-harm T52.1X3 Toxic effect of benzene, assault T52.1X4 Toxic effect of benzene, undetermined T52.2 Toxic effects of homologues of benzene (toluene and xylene) T52.2X Toxic effect of homologues of benzene T52.2X1 Toxic effect of homologues of benzene, accidental (unintentional) T52.2X2 Toxic effect of homologues of benzene, intentional self-harm T52.2X3 Toxic effect of homologues of benzene, assault T52.2X4 Toxic effect of homologues of benzene, undetermined T52.8 Toxic effects of other organic solvents T52.8X Toxic effects of other organic solvents T52.8X1 Toxic effect of other organic solvents, accidental (unintentional) T52.8X2 Toxic effect of other organic solvents, intentional self-harm T52.8X3 Toxic effect of other organic solvents, assault T52.8X4 Toxic effect of other organic solvents, undetermined T52.9 Toxic effects of unspecified organic solvent T52.91 Toxic effect of unspecified organic solvent, accidental (unintentional) T52.92 Toxic effect of unspecified organic solvent, intentional self-harm T52.93 Toxic effect of unspecified organic solvent, assault T52.94 Toxic effect of unspecified organic solvent, undetermined T Codes (cont.) T Codes (cont.) T56.8 Toxic effects of other metals T56 Toxic effect of metals T56.0 Toxic effects of lead and its compounds T56.0X Toxic effects of lead and its compounds T56.0X1 Toxic effects of lead and its compounds, accidental (unintentional) T56.0X2 Toxic effects of lead and its compounds intentional self-harm T56.0X3 Toxic effects of lead and its compounds, assault T56.0X4 Toxic effects of lead and its compounds, undetermined T56.1 Toxic effects of mercury and its compounds T56.1X Toxic effects of mercury and its compounds T56.1X1 Toxic effects of mercury and its compounds, accidental (unintentional) T56.1X2 Toxic effects of mercury and its compounds, intentional self-harm T56.1X3 Toxic effect of mercury and its compounds, assault T56.1X4 Toxic effect of mercury and its compounds, undetermined T56.89 Toxic effects of other metals T Toxic effect of other metals, accidental (unintentional) T Toxic effect of other metals, intentional self-harm T Toxic effect of other metals, assault T Toxic effect of other metals, undetermined T56.9 Toxic effects of unspecified metal T56.91 Toxic effect of unspecified metal, accidental (unintentional) T56.92 Toxic effect of unspecified metal, intentional self-harm T56.93 Toxic effect of unspecified metal, assault T56.94 Toxic effects of unspecified metal, undetermined T57.0 Toxic effect of arsenic and its compounds T57.0X Toxic effect of arsenic and its compounds T57.0X1 Toxic effect of arsenic and its compounds, accidental (unintentional) T57.0X2 Toxic effect of arsenic and its compounds, intentional self-harm T57.0X3 Toxic effect of arsenic and its compounds, assault T57.0X4 Toxic effect of arsenic and its compounds, undetermined T Codes (cont.) T Codes (cont.) T57.2X Toxic effect of manganese and its compounds T57.2X1 Toxic effect of manganese and its compounds, accidental (unintentional) T57.2X2 Toxic effect of manganese and its compounds, intentional self-harm T57.2X3 Toxic effect of manganese and its compounds, assault T57.2X4 Toxic effect of manganese and its compounds, undetermined T58 Toxic effect of carbon monoxide T58.0 Toxic effect of carbon monoxide from motor vehicle exhaust T58.01 Toxic effect of carbon monoxide from motor vehicle exhaust, accidental (unintentional) T58.02 Toxic effect of carbon monoxide from motor vehicle exhaust, intentional self-harm T58.03 Toxic effect of carbon monoxide from motor vehicle exhaust, assault T58.04 Toxic effect of carbon monoxide from motor vehicle exhaust, undetermined T58.1 Toxic effect of carbon monoxide from utility gas T58.11 Toxic effect of carbon monoxide from utility gas, accidental (unintentional) T58.12 Toxic effect of carbon monoxide from utility gas, intentional self-harm T58.13 Toxic effect of carbon monoxide from utility gas, assault T58.14 Toxic effect of carbon monoxide from utility gas, undetermined T58.2 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels T58.2X Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels T58.2X1 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, accidental (unintentional) T58.2X2 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, intentional self-harm T58.2X3 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, assault T58.2X4 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, undetermined T58.8 Toxic effect of carbon monoxide from other source T58.8X Toxic effect of carbon monoxide from other source T58.8X1 Toxic effect of carbon monoxide from other source, accidental (unintentional) T58.8X2 Toxic effect of carbon monoxide from other source, intentional self-harm T58.8X3 Toxic effect of carbon monoxide from other source, assault T58.8X4 Toxic effect of carbon monoxide from other source, undetermined T58.9 Toxic effect of carbon monoxide from unspecified source T58.91 Toxic effect of carbon monoxide from unspecified source, accidental (unintentional) T58.92 Toxic effect of carbon monoxide from unspecified source, intentional self-harm T58.93 Toxic effect of carbon monoxide from unspecified source, assault T58.94 Toxic effect of carbon monoxide from unspecified source, undetermined T59 Toxic effect of other gases, fumes and vapors (includes aerosol propellants) 27

28 Other Codes To Be Used With the H and T codes, If Applicable Other Codes (cont.) A00-A09 Intestinal Infections Diseases A04.7 Clostridium difficile (C-diff) A40-A41.9 Streptococcal and other sepsis A49-A49.9 Bacterial infection of unspecified site B50-B54 Plasmodium falciparum malaria and other malaria codes B95-B95.8 Streptococcus, Staphlococcus, and Enterococcus as the cause of diseases classified elsewhere. Includes staphylococcus aureus and MRSA B99-B99.9 Other and unspecified infectious diseases C00-C14.8 Malignant neoplasms C30-C39 Malignant neoplasms of respiratory and intrathoracic organs, including head and neck and lung C34-C34.92 Malignant neoplasms of bronchus and lung C43.2-C43.4 Melanoma and other malignant neoplasms of skin C4A.2-C4A.4 Merkel cell carcinoma of eye, external auricular canal, parts of face, scalp and neck C44.2-C44.49 Other and unspecified malignant neoplasm of skin of ear and external auricular canal, face, scalp and neck C47.0 Malignant neoplasm of head, face and neck C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck C50-C Malignant neoplasm of breast C51-C58 Malignant neoplasms of female genital organs C60-C63.9 Malignant neoplasms of male genital organs C64-C68.9 Malignant neoplasms of urinary tract C71-C71.9 Malignant neoplasms of brain and other parts of central nervous system C72.4-C72.59 Malignant neoplasm of acoustic nerve and unspecified cranial nerves C79-C79.89 Secondary Malignant neoplasm of other and unspecified sites Other Codes (cont.) T Codes (cont.) D00-D00.1 Carcinoma in situ of oral cavity, esophagus and stomach D02-D02.4 Carcinoma in situ of middle ear and respiratory system D03-D03.4 Melanoma in situ of lip, eyelid, external ear canal and scalp and neck D03.52 Melanoma in situ of breast (skin) (soft tissue) D04.2-D04.22 Carcinoma in situ of skin of ear and external auricular canal D05-D09.9 Carcinoma in situ of breast D10-D11.9 Benign neoplasm of mouth and pharynx D14-D14.4 Benign neoplasm of middle ear and respiratory system D17-D17.0 Benign lipomatous neoplasm and of head, face and neck D37.0-D37.09 Neoplasm of uncertain behavior of oral cavity and pharynx D38-D38.0 Neoplasm of uncertain behavior of middle ear and respiratory and intrathoracic organs D39-D41.9 Neoplasm of uncertain behavior of female genital organs, male organs and urinary organs D42-D42.9 Neoplasm of uncertain behavior of meninges D43-D43.9 Neoplasm of uncertain behavior of brain and central nervous system D48.6-D48.62 Neoplasm of uncertain behavior of breast D49.3-D49.6 Neoplasm of unspecified behavior of breast, bladder, outer genitourinary organs and brain T59 Toxic effect of other gases, fumes and vapors (includes aerosol propellants) T70.0XXA Otic barotrauma, initial encounter T70.0XXD Otic barotrauma, subsequent encounter T70.0XXS Otic barotrauma, sequela Z: Factors Influencing Health Status and Contact with Health Services Supplemental Codes Supplemental codes Likely to be denied when utilized as the primary code (replaces the ICD 9 V codes) Encounter for other special examination without complaint, suspected or reported diagnosis; the reason for the encounter Z01.10 Encounter for examination and hearing Z01.11 Encounter for exam of ears and hearing with abnormal findings Z Encounter for hearing examination following failed hearing screening Z Encounter for examination of ears and hearing with other abnormal findings Use additional code to identify abnormal findings Z01.12 Encounter for hearing conservation and treatment 28

29 Supplemental Codes Z45 Encounter for adjustment and management of implanted device Z Encounter for adjustment and management of bone conduction device Z Encounter for adjustment and management of cochlear device Z Encounter for adjustment and management of other implanted hearing device Z46.1 Encounter for fitting and adjustment of hearing aid Z57.0 Occupational exposure to noise Z71.2 Person consulting for explanation of examination or test findings Z76.5 Malingerer (Person feigning illness with obvious motivation) Z Contact with and (suspected) exposure to noise Supplemental Codes Z83.52 Family history of ear disorders Z86.69 Personal history of other diseases of the nervous system and sense organs Z96.20 Presence of otological and audiological implant, unspecified Z96.21 Cochlear implant status Z96.22 Myringotomy tube(s) status Z96.29 Presence of other otological and audiological implants Z97.4 Presence of external hearing aid A few others Other Changes G51.0 Bell s Palsy M95.11 Cauliflower ear, right M95.12 Cauliflower ear, left Tinnitus is no longer defined as subjective or objective Conductive HL codes are no longer specified as to anatomy/physical location H90.0x SNHL is no longer categorized as sensory or neural H90.3 is SNHL ICD-10-CM codes for Speech-Language Pathologists-Voice ICD-10-CM Codes for SLPs (swallowing disorders) R49.9 Unspecified voice and resonance disorder R49.1 Aphonia R49.0 Dysphonia R49.21 Hypernasality R49.22 Hyponasality R49.8 Other voice and resonance disorders R13.0 Aphagia R13.10 Dysphagia, unspecified R13.11 Dysphagia, oral phase R13.12 Dysphagia, oropharyngeal phase R13.13 Dysphagia, pharyngeal phase R13.19 Other dysphagia R63.3 Feeding difficulties 29

30 I , I for SLPs (ASHA) More SLP ICD-10-CM Codes (ASHA) Other Developmental Disorders of Speech and Language F80.82 Social pragmatic communication disorder (Excludes1: Asperger's syndrome [F84.5], autistic disorder [F84.0]) ASHA Note: The "Excludes1" note means that F80.82 may not be reported in conjunction with F84.5 or F84.0. Sequelae of Cerebrovascular Disease Cognitive Deficits Following Nontraumatic Subarachnoid Hemorrhage I Attention and concentration deficit following nontraumatic subarachnoid hemorrhage I Memory deficit following nontraumatic subarachnoid hemorrhage I Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage I Psychomotor deficit following nontraumatic subarachnoid hemorrhage I Frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage I Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage I Other symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage I Unspecified symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage SLP ICD-10 s (cont.) ASHA SLPs ICD-10 Codes (cont.) ASHA Cognitive Deficits Following Nontraumatic Intracerebral hemorrhage I Attention and concentration deficit following nontraumatic intracerebral hemorrhage I Memory deficit following nontraumatic intracerebral hemorrhage I Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage I Psychomotor deficit following nontraumatic intracerebral hemorrhage I Frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage I Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage I Other symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage I Unspecified symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage Cognitive Deficits Following Other Nontraumatic Intracranial Hemorrhage I Attention and concentration deficit following other nontraumatic intracranial hemorrhage I Memory deficit following other nontraumatic intracranial hemorrhage I Visuospatial deficit and spatial neglect following other nontraumatic intracranial hemorrhage I Psychomotor deficit following other nontraumatic intracranial hemorrhage I Frontal lobe and executive function deficit following other nontraumatic intracranial hemorrhage I Cognitive social or emotional deficit following other nontraumatic intracranial hemorrhage I Other symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage I Unspecified symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage SLP ICD-10 Codes (cont.) ASHA SLP ICD-10 Codes (cont.) ASHA Cognitive Deficits Following Cerebral Infarction I Attention and concentration deficit following cerebral infarction I Memory deficit following cerebral infarction I Visuospatial deficit and spatial neglect following cerebral infarction I Psychomotor deficit following cerebral infarction I Frontal lobe and executive function deficit following cerebral infarction I Cognitive social or emotional deficit following cerebral infarction I Other symptoms and signs involving cognitive functions following cerebral infarction I Unspecified symptoms and signs involving cognitive functions following cerebral infarction Cognitive Deficits Following Other Cerebrovascular Disease I Attention and concentration deficit following other cerebrovascular disease I Memory deficit following other cerebrovascular disease I Visuospatial deficit and spatial neglect following other cerebrovascular disease I Psychomotor deficit following other cerebrovascular disease I Frontal lobe and executive function deficit following other cerebrovascular disease I Cognitive social or emotional deficit following other cerebrovascular disease I Other symptoms and signs involving cognitive functions following other cerebrovascular disease I Unspecified symptoms and signs involving cognitive functions following other cerebrovascular disease 30

SLP ICD-10 Codes (cont.) ASHA Revised SLP ICD-10 Codes (ASHA) Cognitive Deficits Following Unspecified Cerebrovascular Disease I69.

911 Memory deficit following unspecified cerebrovascular disease I69.912 Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease I69.

915 Cognitive social or emotional deficit following unspecified cerebrovascular disease I69.

919 Unspecified symptoms and signs involving cognitive functions following unspecified cerebrovascular disease Specific Developmental Disorders of Speech and Language No change F80.

0 Autistic disorder Add Autism spectrum disorder No change F88 Other disorders of psychological development No change Developmental agnosia Add Global developmental delay Add Other specified

add new language to include descriptive information or examples related to disorders captured under each code. Now What?

31 SLP ICD-10 Codes (cont.) ASHA Revised SLP ICD-10 Codes (ASHA) Cognitive Deficits Following Unspecified Cerebrovascular Disease I69.91 Cognitive deficits following unspecified cerebrovascular disease I Attention and concentration deficit following unspecified cerebrovascular disease I Memory deficit following unspecified cerebrovascular disease I Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease I Psychomotor deficit following unspecified cerebrovascular disease I Frontal lobe and executive function deficit following unspecified cerebrovascular disease I Cognitive social or emotional deficit following unspecified cerebrovascular disease I Other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease I Unspecified symptoms and signs involving cognitive functions following unspecified cerebrovascular disease Specific Developmental Disorders of Speech and Language No change F80.0 Phonological disorder Add Speech-sound disorder Pervasive Developmental Disorders No change F84.0 Autistic disorder Add Autism spectrum disorder No change F88 Other disorders of psychological development No change Developmental agnosia Add Global developmental delay Add Other specified neurodevelopmental disorder No change F89 Unspecified disorder of psychological development Add Neurodevelopmental disorder NOS ASHA Note: These revisions do not change the intent of the codes, but add new language to include descriptive information or examples related to disorders captured under each code. Now What? References Continue to monitor claims for denials Review EOBs carefully Provider speed is slower in choosing a code Specificity moratorium ended on 10/1/16 Hopefully will be new codes in the near future Staff should continue to meet to identify problem areas Implement correction plans May include changing documentation processes May need to include additional codes into systems or delete ones never utilized Retrain current staff and train new staff 10 CM/Pages/default.aspx Essential Resources Essential Resources (cont.) ICD-10-CM codebook for non-hospital based audiologists ICD-10-PCS codebook for hospital based audiologists Action=push 31

32 Other Resources (with caution): There s an app for that SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. Break! 32

33 Medicare Requirements Medicare Requirements for Audiologists The most stringent of all payers Many commercial payers guidance is based on that of Medicare s Audiologists and SLPs can not opt out of Medicare Must enroll if providing diagnostic services and billing for them If a Medicare beneficiary requests you file the claim, you must due to the mandatory claim statute Medicare requires a physician order and the audiologic and/or vestibular evaluations are to be based on medical necessity What is Medical Necessity? For those things that are statutorily excluded: Title XVIII of the Social Security Act, section 1862 (a)(1)(a): Notwithstanding any other provisions of this tile, no payment may be made under Part A or Part B for any 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 Anything not medically necessary What is medical necessity? necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. May be located in the Local Coverage Determination policy Needed for the diagnosis or treatment of a medical condition Provided for the diagnosis, direct care and treatment of the patient s medical condition Meets the standard of good health practice Is not for the convenience of the patient or health care practitioner Williams, Burton and Abel, Audiology Today. Vol. 20 (6) Medicare Enrollment Audiology services are in the other diagnostic test category for Medicare Other diagnostic tests are not (or ever) to be billed incident to In April, 2008 the Centers for Medicare and Medicaid Services issued Transmittal 84 Recognition by CMS Clarification of widely accepted incorrect billing practices of audiologic diagnostic services Medicare Requirements for Audiologists Audiology statute allows reimbursement only for diagnostic procedures: Sec [42 U.S.C. 1395x] of the Social Security Act The term audiology services means such hearing and balance assessment services furnished by a qualified audiologist as the audiologist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), as would otherwise be covered if furnished by a physician 33

34 Medicare (cont.) Medicare (cont.) (B) The term qualified audiologist means an individual with a master's or doctoral degree in audiology who (i) is licensed as an audiologist by the State in which the individual furnishes such services, or (ii) in the case of an individual who furnishes services in a State which does not license audiologists, has successfully completed 350 clock hours of supervised clinical practicum (or is in the process of accumulating such supervised clinical experience), performed not less than 9 months of supervised full-time audiology services after obtaining a master's or doctoral degree in audiology or a related field, and successfully completed a national examination in audiology approved by the Secretary. Audiologists and SLPs are not on the list of providers who may opt out of Medicare You must be enrolled unless all services for all patients is at no charge Learn the rules for your contractor and monitor the Local Coverage Determination policies: nc.+% %2c+mac+-+part+b%29&s=46&doctype=all&bc=aggaaaaaaaaaaa%3d%3d& Tidbits SlidesCarnival icons are editable shapes. MLN/MLNMattersArticles/downloads/SE1311.pdf A Medicare patient cannot pay more for the same service than another patient (OIG) All patients must be charged the same amount for services For those Medicare patients on whom you cannot collect, if you show a good faith effort in collecting, on a case-by-case basis, fees can then be written off For all patients, have a financial agreement to collect the required co-pay Due to the Medicare Access and CHIP Reauthorization Act of 2015, we will continue to enjoy a 0.5% payment update through 2019 Afterwards, payments will be frozen until 2025 Payment Impact on SLPs SLPs and The Therapy Cap Conversion Factor for 2016 is $ Conversion Factor for 2015 was $ MACRA eliminated the Sustainable Growth Rate Multiple Procedure Payment Reductions (MPPR) Reimbursement is decreased when multiple codes are performed on the same date of service in the same facility Applies to some speech-language pathology codes AND includes physical AND occupational therapies Increased therapy cap $20 from 2015 to 2016: from $1940 to $1960 for SLP and PT services Until 12/31/17, can use KX modifier for services exceeding the cap Medical review process provided at or above $3700 is in effect until 12/31/17 34

35 SLPs and Incident to Other Tidbits SLPs are currently allowed to have services billed to Medicare via the NPI of a physician as part of services that are integral to the care provided by the ordering physician. Direct supervision is required by physician: Must be in the office and available Is essentially for technicians Audiologists are not to have their services billed via the NPI of the physician If required by a third party payer, referring provider must be on the CMS 1500 claim form Medicare provider orders: On the physician s letterhead or prescription pad May want to avoid referral pads with your practice name to avoid solicitation Check with Noridian (Medicare contractor) Medicare (cont.) Medicare (cont.) Chapter 15-Covered Medical and Other Health Services, Medicare Benefits Policy Manual -80 Requirements for Diagnostic X-ray, Diagnostic Laboratory, and Other Diagnostic Tests 80.3 Audiological Diagnostic Testing A. Benefit. Hearing and balance assessment services are generally covered as "other diagnostic tests" under section 1861(s)(3) of the Social Security Act. Hearing and balance assessment services furnished to an outpatient of a hospital are covered as "diagnostic services" under section 1861(s)(2)(C). Audiological diagnostic tests are not covered under the benefit for services incident to a physician s service (described in Pub , chapter 15, section 60), because they have their own benefit as other diagnostic tests. See Pub , chapter 13 for general diagnostic test policies. Medicare (cont.) Medicare (cont.) Medicare considers us to be only diagnosticians by virtue of the other diagnostic tests category Requires a physician order for a medically necessary reason Medicare services are predicated on medical necessity oday/2008atnovdec.pdf Direct Access will remove the order requirement, but medical necessity will remain in effect and will be required Medical necessity is not just a Medicare requirement Required by all payers When a qualified physician or qualified nonphysician practitioner orders a specific audiological test using the CPT descriptor for the test, only that test may be performed for that order. Further orders are necessary if the ordered test indicates that other tests are necessary to evaluate, for example, the type or cause of the condition. Orders for specific tests are required for technicians. (MBPM Chapter 15) 35

36 Medicare (cont.) Medicare (cont.) When the qualified physician or qualified nonphysician practitioner orders diagnostic audiological tests by an audiologist without naming specific tests, the audiologist may select the appropriate battery of tests. (MBPM, Chapter 15) Coverage and Payment for Audiological Services. Diagnostic services performed by a qualified audiologist and meeting the requirements at 1861(ll)(3)(B) are payable as other diagnostic tests. Audiological diagnostic tests are not covered as services incident to physician s services or as services incident to audiologist s services. (MBPM, Chapter 15) Medicare (cont.) Medicare (cont.) The payment for audiological diagnostic tests is determined by the reason the tests were performed, rather than by the diagnosis or the patient s condition. (MBPM, Chapter 15) If a beneficiary undergoes diagnostic testing performed by an audiologist without a physician order, the tests are not covered even if the audiologist discovers a pathologic condition. (MBPM Chapter 15) Medicare (cont.) Medicare (cont.) Payment for audiological diagnostic tests is not allowed by virtue of 1862(a)(7) when: The type and severity of the current hearing, tinnitus or balance status needed to determine the appropriate medical or surgical treatment is known to the physician before the test; or The test was ordered for the specific purpose of fitting or modifying a hearing aid. (MBPM, Chapter 15) Re-evaluation: Is appropriate at a schedule dictated by the ordering physician when the information provided by the diagnostic test is required, for example, to determine changes in hearing, to evaluate the appropriate medical or surgical treatment or evaluate the results of treatment. (MBPM, Chapter 15) 36

37 Medicare (cont.) Medicare (cont.) If a physician refers a beneficiary to an audiologist for testing related to signs or symptoms associated with hearing loss, balance disorder, tinnitus, ear disease, or ear injury, the audiologist s diagnostic testing services should be covered even if the only outcome is the prescription of a hearing aid. (MPBM, Chapter 15) The technical components of certain audiological diagnostic tests i.e., tympanometry (92567) and vestibular function tests (e.g., 92541) that do not require the skills of an audiologist may be performed by a qualified technician or by an audiologist, physician or nonphysician practitioner acting within their scope of practice. If performed by a technician, the service must be provided under the direct supervision [42 CFR (3)] of a physician or qualified nonphysician practitioner who is responsible for all clinical judgment and for the appropriate provision of the service. The physician or qualified nonphysician practitioner bills the directly supervised service as a diagnostic test. (MBPM, Chapter 15) Audiology Codes That Have a Technical and Professional Component TC/PC split Vestibular CPT codes ( , 92548) (vertical electrodes) does not have the TC/PC split Florida s Local Coverage Determination Medicare policy specifies this code for use for ENG and VNG Comprehensive ABR CPT code (92585) OAE CPT codes (92587, 92588) If a technician performs the test, that can be billed incident to the physician, if they directly supervised the test (e.g., TC) The interpretation and report can be billed by an audiologist or physician (e.g., ) If the audiologist performs both the test and does the interpretation and report, it is billed with the global code (92585) TC + PC = Same reimbursement for global code Medicare (cont.) Specialties who can order/refer for beneficiary services, Part B and DMEPOS, if allowed by state licensure The other diagnostic tests benefit requires an order from a physician, or, where allowed by State and local law, by a non-physician practitioner. (MBPM, Chapter 15) Doctor of Medicine or Osteopathy, Doctor of Dental Medicine Doctor of Dental Surgery Doctor of Podiatric Medicine Doctor of Optometry Doctor of Chiropractic Medicine Physician Assistant Certified Clinical Nurse Specialist Nurse Practitioner Clinical Psychologist Certified Nurse Midwife Clinical Social Worker (CMS Medlearn Fact Sheet: ICN April 2011) 37

38 What else? Medicare (cont.) Who is the referring professional if required by a third party payer? Medicare physician referrals: On the physician s letterhead or prescription pad Not to have the appearance that it was solicited by you May want to avoid referral pads with your practice name Check with your Medicare contractor (First Coast) The reason for the test should be documented either on the order, on the audiological evaluation report, or in the patient s medical record. Examples of appropriate reasons include but are not limited to: Evaluation of suspected change in hearing, tinnitus, or balance; Evaluation of the cause of disorders of hearing, tinnitus, or balance. Determination of the effect of medication, surgery or other treatment (MBPM, Chapter 15) Medicare (cont.) Medicare (cont.) The medical record shall identify the name and professional identity of the person who ordered and the person who actually performed the service. When the medical record is subject to medical review, it is necessary that the contractor determine that the service qualifies as an audiological diagnostic test that requires the skills of an audiologist. (MBPM, Chapter 15) Audiology transmittals (84, 127, 1975, 2007, 2044) Diagnostic services performed by an audiologist are to be billed with the NPI of the audiologist Contractors shall not pay for services performed by audiologists and billed under the NPI of a physician. Contractors shall not pay for audiological services incident to the service of a physician or nonphysician practitioner. Medicare Requirements Medicare Requirements for Audiologists Audiologists can not opt out of Medicare Must enroll if providing diagnostic services and billing for them If not enrolled, they are to be free to every patient If a Medicare beneficiary requests you file the claim, you must as it is required by the mandatory claim statute Many commercial payers guidance is based on that of Medicare s Audiology statute allows reimbursement only for diagnostic procedures: Sec [42 U.S.C. 1395x] of the Social Security Act The term audiology services means such hearing and balance assessment services furnished by a qualified audiologist as the audiologist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), as would otherwise be covered if furnished by a physician 38

39 Medicare (cont.) Medicare (cont.) The reason for the test should be documented either on the order, on the audiological evaluation report, or in the patient s medical record. Examples of appropriate reasons include but are not limited to: Evaluation of suspected change in hearing, tinnitus, or balance; Evaluation of the cause of disorders of hearing, tinnitus, or balance. Determination of the effect of medication, surgery or other treatment (MBPM, Chapter 15) The medical record shall identify the name and professional identity of the person who ordered and the person who actually performed the service. When the medical record is subject to medical review, it is necessary that the contractor determine that the service qualifies as an audiological diagnostic test that requires the skills of an audiologist. (MBPM, Chapter 15) Medicare (cont.) Medicare (cont.) Audiological Treatment. There is no provision in the law for Medicare to pay audiologists for therapeutic services. For example, vestibular treatment, auditory rehabilitation and auditory processing treatment, while they are within the scope of practice of audiologists, are not diagnostic tests, and therefore, shall not be billed by audiologists to Medicare. (MBPM, Chapter 15) Audiology transmittals (84, 127, 1975, 2007, 2044) Diagnostic services performed by an audiologist are to be billed with the NPI of the audiologist. Contractors shall not pay for services performed by audiologists and billed under the NPI of a physician. Contractors shall not pay for audiological services incident to the service of a physician or nonphysician practitioner. Medicare Audiology Transmittals Contractors shall not pay for the technical component of audiological diagnostic tests performed by a qualified technician unless the physician or nonphysician supervisor who provides the direct supervision documents clinical decision making and active participation in delivery of the service. Medicare Audiology Transmittals Contractors shall not pay for services that require the skills of an audiologists when furnished by an AuD 4 th year student or others who are not qualified according to section 1861(II)(3) of the Act. Although AuD 4 th year students, and other audiology students, do not meet the current requirements in statute to provide audiology services, they may meet standards equivalent to audiology technicians. 39

40 Medicare Audiology Transmittals Audiology services must be personally furnished by an audiologist, or nonphysician practitioner (NPP). Physicians may personally furnish audiology services, and technicians or other qualified staff may furnish those parts of a service that do not require professional skills under the direct supervision of physicians. Medicare Audiology Transmittals Orders are required for audiology services in all settings. Coverage and, therefore, payment for audiological diagnostic tests is determined by the reason the tests were performed, rather than by the diagnosis or the patient's condition. Medicare Medicare will not pay for services performed by audiologists and billed under the NPI of a physician. In denying such claims, Medicare will use: CARC 170 (Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.); and Remittance Advice Remark Code (RARC) N290 (Missing/incomplete/invalid rendering provider primary identifier.) Medicare Audiology Transmittals Audiology services must be personally furnished by an audiologist, or nonphysician practitioner (NPP). Physicians may personally furnish audiology services, and technicians or other qualified staff may furnish those parts of a service that do not require professional skills under the direct supervision of physicians. Medicare Audiology Transmittals Medicare Guidance Orders are required for audiology services in all settings. Coverage and, therefore, payment for audiological diagnostic tests is determined by the reason the tests were performed, rather than by the diagnosis or the patient's condition. Revisions and Re-Issuance of Audiology Policies per Section 1861 (ll) (3) of the Social Security Act, audiology services are defined as such hearing and balance assessment services furnished by a qualified audiologist as the audiologist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), as would otherwise by covered if furnished by a physician. These hearing and balance assessment services are termed audiology services, regardless of whether they are furnished by an audiologist, physician, nonphysician practitioner (NPP), or hospital. 40

41 Revisions and Re-Issuance (cont.) Revisions and re-issuance (cont.) Qualifications The individuals who furnish audiology services in all settings must be qualified to furnish those services. The qualifications of the individual performing the services must be consistent with the number, type and complexity of the tests, the abilities of the individual, and the patient s ability to interact to produce valid and reliable results. The physician who supervises and bills for the service is responsible for assuring the qualifications of the technician, if applicable, are appropriate to the test. The opt out law does not define physician or practitioner to include audiologists; therefore, they may not opt out of Medicare and provide services under private contracts. Revisions and Re-issuance (cont.) Revisions and Re-issuance (cont.) When a professional personally furnishes an audiology service, that individual must interact with the patient to provide professional skills and be directly involved in decision-making and clinical judgment during the test. The skills required when professionals furnish audiology services for payment under the MPFS are masters or doctoral level skills that involve clinical judgment or assessment and specialized knowledge and ability including, but not limited to, knowledge of anatomy and physiology, neurology, psychology, physics, psychometrics, and interpersonal communication. The interactions of these knowledge bases are required to attain the clinical expertise for audiology tests. Also required are skills to administer valid and reliable tests safely, especially when they involve stimulating the auditory nerve and testing complex brain functions. Revisions and re-issuance (cont.) Revisions and re-issuance (cont.) Diagnostic audiology services also require skills and judgment to administer and modify tests, to make informed interpretations about the causes and implications of the test results in the context of the history and presenting complaints, and to provide both objective results and professional knowledge to the patient and to the ordering physician. For claims with dates of service on or after October 1, 2008 audiologists are required to be enrolled in the Medicare program and use their National Provider Identifier (NPI) on all claims for services they render in office settings. 41

42 Revisions and re-issuance (cont.) Revisions and re-issuance (cont.) For audiologists who are enrolled and bill independently for services they render, the audiologist s NPI is required on all claims they submit. For example, in offices and private practice settings, an enrolled audiologist shall use his or her own NPI in the rendering loop to bill under the MPFS for the services the audiologist furnished. If an enrolled audiologist furnishing services to hospital outpatients reassigns his/her benefits to the hospital, the hospital may bill the Medicare contractor for the professional services of the audiologist under the MPFS using the NPI of the audiologist. If an audiologist is employed by a hospital but is not enrolled in Medicare, the only payment for a hospital outpatient audiology service that can be made is the payment to the hospital for its facility services under the hospital Outpatient Prospective Payment System (OPPS) or other applicable hospital payment system. No payment can be made under the MPFS for professional services of an audiologist who is not enrolled. Audiology services may be furnished and billed by audiologists and, when these services are furnished by an audiologist, no physician supervision is required. Revisions and re-issuance Revisions and re-issuance (cont.) When a physician or supplier furnishes a service that is covered by Medicare, then it is subject to the mandatory claim submission provisions of section 1848(g)(4) of the Social Security Act. Therefore, if an audiologist charges or attempts to charge a beneficiary any remuneration for a service that is covered by Medicare, then the audiologist must submit a claim to Medicare. Medicare will not pay for an audiological test under the MPFS if the test was performed by a technician under the direct supervision of a physician if the test requires professional skills. Such claims will be denied using Claim Adjustment Reason Code (CARC) 170 (Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.). Revisions and re-issuance (cont.) Revisions and re-issuance (cont.) Medicare will not pay for audiological tests furnished by technicians unless the service is furnished under the direct supervision of a physician. In denying claims under this provision, Medicare will use: CARC 185 (The rendering provider is not eligible to perform the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.); and RARC M136 (Missing/incomplete/invalid indication that the service was supervised or evaluated by a physician.) Medicare will pay physicians and NPPs for treatment services furnished by audiologists incident to physicians services when the services are not on the list of audiology services at and are not always therapy services and the audiologist is qualified to perform the service. Update.html 42

43 Revisions and re-issuance (cont.) Revisions and re-issuance (cont.) All audiological diagnostic tests must be documented with sufficient information so that Medicare contractors may determine that the services do qualify as an audiological diagnostic test. The interpretation and report shall be written in the medical record by the audiologist, physician, or NPP who personally furnished any audiology service, or by the physician who supervised the service. Technicians shall not interpret audiology services, but may record objective test results of those services they may furnish under direct physician supervision. Payment for the interpretation and report of the services is included in payment for all audiology services, and specifically in the professional component (PC), if the audiology service has a professional component/technical component split. Revisions and re-issuance (cont.) Revisions and re-issuance (cont.) When Medicare contractors review medical records of audiological diagnostic tests for payment under the MPFS, they will review the technician s qualifications to determine whether, under the unique circumstances of that test, a technician is qualified to furnish the test under the direct supervision of a physician. The PC of a PC/TC split code may be billed by the audiologist, physician, or NPP who personally furnishes the service. (Note this is also true in the facility setting.) A physician or NPP may bill for the PC when the physician or NPP furnish the PC and an (unsupervised) audiologist furnishes and bills for the TC. The PC may not be billed if a technician furnishes the service. A physician or NPP may not bill for a PC service furnished by an audiologist. Revisions and re-issuance (cont.) Revisions and re-issuance (cont.) The global service is billed when both the PC and TC of a service are personally furnished by the same audiologist, physician, or NPP. The global service may also be billed by a physician, but not an audiologist or NPP, when a technician furnishes the TC of the service under direct physician supervision and that physician furnishes the PC, including the interpretation and report. Tests that have no appropriate CPT code may be reported under CPT code (Unlisted otorhinolaryngological service or procedure). 43

44 Summary of Medicare Audiology Service Provision SLPs and Medicare Medicare only reimburses licensed audiologists for diagnostic procedures, with a physician order, for a medically necessary reason, by way of a claim with a date of service not older than one calendar year of filing, from the same physician fee schedule as physicians, with the audiologist s NPI. SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. 44

45 SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. 45

include routine annual testing May include a partial payment for hearing aid(s) Participating provider Non-participating provider Limiting Charge provider 2016

46 SlidesCarnival icons are editable shapes. Medicare Part C (Advantage Plans) Status within Medicare Requires fraud and abuse training annually Provide services above what traditional Medicare does not May include routine annual testing May include a partial payment for hearing aid(s) Participating provider Non-participating provider Limiting Charge provider 2016 Medicare Physician Fee Schedule for Montana Resource: CPT code Participating Non-par Limiting Charge ch-and- Education/Medicare- Learning-Network- MLN/MLNProducts/D ownloads/how_to_mp FS_Booklet_ICN pdf 46

http://www.cms.go v/outreach-and- Education/Medicar e-learning- Network- MLN/MLNEdWebG uide/downloads/g uided_pathways_p rovider_specific_b ooklet.

Medicare Beneficiary Rights Social Security Act ( 1848(g)(4) requires that claims be submitted for all Medicare patients for services rendered on or after September 1, 1990.

assignment (CMS MLN Matters Number SE0908) ABNs Advanced Beneficiary Notice Mandatory ABN: When Medicare is expected to deny payment (entirely or in part) for the item or

Voluntary ABN: not required for care that is statutorily excluded or for services for which no Medicare benefit category exists.

medical necessity Provider uncertain if Medicare does cover for some diagnoses, may not be for this particular instance Voluntary Non-covered, statutorily excluded, services

47 v/outreach-and- Education/Medicar e-learning- Network- MLN/MLNEdWebG uide/downloads/g uided_pathways_p rovider_specific_b ooklet.pdf SlidesCarnival icons are editable shapes. Medicare Beneficiary Rights Social Security Act ( 1848(g)(4) requires that claims be submitted for all Medicare patients for services rendered on or after September 1, Applies to all providers who provide covered services to Medicare beneficiaries The requirement to submit Medicare claims does not mean physicians or suppliers must accept assignment (CMS MLN Matters Number SE0908) ABNs Advanced Beneficiary Notice Mandatory ABN: When Medicare is expected to deny payment (entirely or in part) for the item or service because it is not reasonable and necessary under Medicare Program standards. Voluntary ABN: not required for care that is statutorily excluded or for services for which no Medicare benefit category exists. Example of Medicare Program exclusions are: Hearing aids and hearing examinations Required (mandatory) Provider believes Medicare may deny the service due to not meeting medical necessity Provider uncertain if Medicare does cover for some diagnoses, may not be for this particular instance Voluntary Non-covered, statutorily excluded, services such as treatment or rehabilitation Vestibular rehabilitation Cerumen management Tinnitus management Other applications Covered vs. Non-Covered SlidesCarnival icons are editable shapes. Covered services: Patient notices a change in their hearing, equilibrium, tinnitus Medical necessity Physician order Non-covered services: Hearing aids Annual routine hearing evaluations Patient who comes in without a physician order Rehab/treatment In our scope of practice Patients pay privately 47

Resource: SlidesCarnival icons are editable shapes. http://www.cms.

p df Three options on the ABN: Medicare Modifiers 1.

Item or service is statutorily excluded or does not meet the definition of any Medicare benefit Often used when a

as Required by Payer Policy To be used when a denial is expected and an ABN is on file No ABN, no billing the

excluded GZ Item or service expected to be denied as not reasonable and necessary To be used when there is no ABN on

Medicare Enrollment Provider Enrollment Chain, Ownership System (PECOS) Online system for initial enrollment and

48 Resource: SlidesCarnival icons are editable shapes. Learning-Network- MLN/MLNProducts/downloads/abn_booklet_icn p df Three options on the ABN: Medicare Modifiers 1. Bill Medicare By signing and utilizing option 1, you can bill Medicare and bill the patient if the claim is denied 2. Don t bill Medicare 3. Patient declines procedure Itemizes: Patient s name Date of service Procedure(s) performed Costs to be incurred GY Item or service is statutorily excluded or does not meet the definition of any Medicare benefit Often used when a secondary insurance has a hearing aid benefit and requires a Medicare denial GA Waiver of Liability Statement Issued as Required by Payer Policy To be used when a denial is expected and an ABN is on file No ABN, no billing the patient GX Notice of Liability Issued, Voluntary Under Payor Policy For services that are non covered, statutorily excluded GZ Item or service expected to be denied as not reasonable and necessary To be used when there is no ABN on file; likely to be utilized in an emergency situation; patient is not responsible for payment Also for SLPs (ASHA): Medicare Enrollment Provider Enrollment Chain, Ownership System (PECOS) Online system for initial enrollment and revalidation Update current information Check enrollment status Must report changes to contractor no later than 90 days after the change unless A change in ownership or managing interest (within 30 days) DMEPOS must notify the National Supplier Clearinghouse of changes in enrollment (within 30 days) 48

49 Medicare Enrollment Medicare Enrollment Independent, contracting audiologists should have an 855R for all facilities where they provide services Each one needs to be itemized on the 855I Addresses, names of facilities need to match Site visits are being conducted to ensure the legitimacy of the facility Medicare 101 Par, Non-Par, Limiting Charge Medicare Participation Participating Provider You bill Medicare, they pay you Patient pays their co-insurance to you Non-participating Provider You bill Medicare, they pay patient Patient pays you Results in 5% less than par Limiting Charge Provider You bill Medicare, they pay patient Patient pays you Results in the highest level of Medicare reimbursement: 10% over participating Medicare 101 Medicare 101 Medicare Participating Provider Patient pays you their 20% co-insurance You bill Medicare Medicare pays you the 80% of the allowable amount per the Medicare Physician Fee Schedule Medicare Non-Participating Provider Patient pays you their 80% allowable You bill Medicare Medicare pays the patient 80% of the allowable amount per the Medicare Physician Fee Schedule and their co-insurance Challenging in an economically depressed area Medicare 101 (cont.) Medicare Enrollment Medicare Limiting Charge Provider Patient pays you their 80% allowable and co-insurance You bill Medicare Medicare pays the patient 80% of the allowable amount per the Medicare Physician Fee Schedule and their co-insurance You receive 10% more of the MPFS than a participating provider Challenging in an economically depressed area May apply and receive the required Provider Transaction Access Number (PTAN) via one of two ways: On-line: Provider Enrollment, Chain and Ownership System (PECOS) online 49

50 Medicare Enrollment Medicare Enrollment CMS 855I paper application (Dated 7/11) Hard copy Submit an 855I for an individual provider If a sole practitioner or Incorporated Independent CMS 460 (For participation) CMS 580 (Electronic funds transfer) May also need to file the 855R, to re-assign the benefits to employer or to contractor: Most recent form is dated 11/12 Submit an 855S if providing (DME) Cochlear implants Osseo-integrated devices (Bahas, Pontos) Providers who submit the 855A or 855S must pay a fee Medicare Enrollment (Group) Medicare Enrollment (cont.) Submit an 855B if group (2 or more providers) If already enrolled in Medicare via an 855I: Must file an CMS 855B Must file an CMS 855R Must file an CMS 580 CMS 460 if participating If enrolling first time, submit: CMS 855I CMS 855B CMS 855R CMS 580 CMS 460 if participating MUST BE ENROLLED IN PECOS All providers enrolling must also submit a CMS-588 Electronic Funds Transfer (EFT) Direct deposit Contractor will not be able to withdraw funds for any overpayments MLN Matters Number SE1126 Revised What will you need to use PECOS? Medicare Enrollment National Provider Identifier (NPI) Other identifying information: Legal business name/tin of the provider or organization Bank account information Practice address(es) Business license(s) Information about any final adverse actions Submit Certification Statement ASAP after submitting internet enrollment, ideally no more than one week after submitting the application if hard copy and via USPS Processing is not permitted until the Certification Statement is received Must be signed and dated Must include documentation (state license, terminal degree) Effective date of filing is the date the Certification Statement is received by contractor, if PECOS submission was successful Original signature (Blue) ink 50

51 Medicare Enrollment Medicare Enrollment Submission Receipt confirms the application has been submitted successfully May print a copy for your records Do not submit the printed copy to Contractor Data cannot be edited after submission unless the contractor requests additional information After 15 days, can check status: Received by the Medicare Enrollment Contractor Reviewed by the Medicare Enrollment Contractor Returned for Additional Information Respond within 30 days of the request If not, may cause delay or application may be rejected Approved or rejected Final status Medicare Enrollment Medicare Enrollment PECOS enrollment: CMS requires 90% of the applications be processed within 45 days of receipt of the signed/dated Certification Statement Paper enrollment CMS requires 80% of the applications be processed within 60 days for initial enrollment 80% of paper changes within 45 days Change of information must be reported within 30 days of any of these changes except for the last item: Move to a new/different facility/organization* Change in practice location* Change in practice ownership* Adverse legal action* DMEPOS must notify National Supplier Clearinghouses of changes* Change billing services Report immediately! Medicare Easy Remit free software Medicare Enrollment Medicare Enrollment No later than 90 days, report: Change in business structure Sole proprietorship to incorporated structure Change in organization s legal business name/tax identification number (TIN) Change in practice status Move Retirement Close of practice Deactivation If you have not submitted claims for 12 months Begins on the 1 st day of the 1 st month of no claims submissions through the last day of the 12 th month May not reactivate until ready to submit a new claim Change of information on enrollment form not updated within 90 calendar days of when the change occurred Change of ownership not reported within 30 calendar days Must submit complete 855 s If you have never completed an 855 I or B If you have not completed an 855 I since 2003 Need to update 855 R s with each place you offer services Your practice, if applicable Those with whom you contract 51

Medicare Beneficiary Rights 8550 Social Security Act ( 1848(g)(4) requires that claims be submitted for all Medicare patients for services rendered on or after September 1, 1990.

physicians or suppliers must accept assignment (CMS MLN Matters Number SE0908) Enrollment form https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms855o.

http://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNMattersArticles/downloads/MM7723.

providers are enrolled PECOS SlidesCarnival icons are editable shapes.

52 Medicare Beneficiary Rights 8550 Social Security Act ( 1848(g)(4) requires that claims be submitted for all Medicare patients for services rendered on or after September 1, Have to be enrolled in order to file a claim to Medicare Applies to all providers who provide covered services to Medicare beneficiaries The requirement to submit Medicare claims does not mean physicians or suppliers must accept assignment (CMS MLN Matters Number SE0908) Enrollment form To be completed by certain physicians and non-physician practitioners to enroll in the Medicare program for the sole purpose of ordering and referring items or services for Medicare beneficiaries. MLN/MLNMattersArticles/downloads/MM7723.pdf These providers do not and will not send claims to a Medicare contractor for the services they furnish Application to audiology: referring physicians who are not enrolled, or who have opted out of Medicare. Claims with those referring providers who are not enrolled via the 8550 will result in denied claims Patient can t be billed for these denials Ensure that all your Medicare referring/ordering providers are enrolled PECOS SlidesCarnival icons are editable shapes. Physician Quality Reporting System For Audiologists and Speech-Language Pathologists PQRS 10 audiology organizations have been working on audiology quality measure development since 2008 American Academy of Audiology Academy of Doctors of Audiology American Speech-Language-Hearing Association Academy of Rehabilitative Audiology American Academy of Private Practice in Speech Pathology and Audiology Association of VA Audiologists Directors of Speech and Hearing Programs in State Health and Welfare Agencies Educational Audiology Association Military Audiology Association National Hearing Conservation Association Designed to improve quality of care to Medicare beneficiaries Maximize efficiency; minimize burden for reporting Applies only to Medicare enrolled Part B eligible providers (EP) Not Part A hospital or Skilled Nursing Facilities Must report in 2016 or face a 2% penalty on ALL 2018 Medicare claims Just add the appropriate G or CPT II code on the claim! 52

53 Why Physician Quality Reporting System? 2016 PQRS Measures Reporting Care coordination Track Medicare enrolled quality services Physician Compare Consumer website to locate Medicare providers based on practice information and quality reporting No changes to 3 current measures for audiologists except the depression screening is required when performing CPT code (tinnitus evaluation) Cross-cutting measures (#130, #134, #226) Three new measures: Falls risk assessment (#154) CPT codes 92540, 92541, and/or Falls Plan of Care (#155) CPT codes 92540, 92541, and/or Smoking cessation (#226) CPT codes 92540, and/or No ICD-10-CM codes in these new measures Avoid negative reporting, doesn t count towards avoiding the penalty For SLPs: Measures #130, #131, #226 #130 and #131 are for each visit Required Domains The 9 measures needed to cover 3 National Quality Forum domains: Patient safety (#130, #154 and #155) Person and Caregiver-Centered Experience and Outcomes Communication and Care Coordination (#131 and #261) Effective Clinical Care Community/Population Health (#134, #226) Efficiency and Cost Reduction 2016 Eligible PQRS Measures for Audiologists-The Ones From 2015 #261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness AND #130-Documentation and Verification of Current Medications in the Medical Record AND #134-Screening for Clinical Depression and Follow-Up Plan We continue to have these three 2015 measures in 2016 and three additional potential opportunities (measures) for reporting Of the ones above, #130 and #134 are cross-cutting measures No changes to 3 current measures except the depression screening is required when performing CPT code (tinnitus evaluation))s required when performing CPT code (tinnitus evaluation) No Three changes new to 3 measures: current measures except the depression screening is required Falls risk assessment (#154) No ICD-10-CM codes in these new when performing CPT code (tinnitus evaluation) CPT codes 92540, 92541, and/or measures Cross-cutting measures (#130, #134 and now #226) Falls Plan of Care (#155) If indicated, report once/year CPT codes 92540, 92541, and/or Avoid negative reporting as it doesn t count Preventative Care and Screening: towards avoiding the penalty Tobacco Use (#226) CPT codes 92540, and/or Cross cutting measure PQRS Measure #130 Documentation and Verification of Current Medications in the Medical Record This measure is to be reported at each visit occurring during the reporting period for all patients aged 18 years and older To determine if documentation of a current medication list occurred 53

54 #130 for 2016 Audiology CPT Codes For PQRS #130: Description: Eligible professional attests to documenting, updating or reviewing a patient s current medications using all immediate resources available on the date of encounter. This list must include ALL known prescriptions, overthe-counters, herbals and vitamin/mineral/dietary (nutritional) supplements and must contain the medications name, dosages, frequency and route of administration. CPT Codes: CPT Codes: CPT Codes For SLPs and #130: Clinical Example #130 (cont.) 92507, 92508, 92526, 92626, Report on #130 (and #226) if you performed these CPT codes: No ICD-10 codes required for this measure Clinical Example #130 For 2016 (#130) With two of these example CPT codes included in the measure and since an ICD-10 code is not specified, can report on this measure with G8427 if the following are documented to the best of your ability: The name of the drug, OTC, herbal, vitamin/dietary [nutritional] supplements The dosage of the drug The frequency that it is taken The route of administration (pathway of how it is taken) Topical? IV? Sub-lingual? etc. G8427: Eligible professional attests to documenting in the medical record they obtained, updated, or reviewed the patient s current medications Also report if not taking any medications G8430: Eligible professional attests to documenting in the medical record the patient is not eligible for a current list of medications being obtained, upgraded, or reviewed by the eligible professional THIS WILL RESULT IN NEGATIVE REPORTING AND WILL NOT AVOID THE PENALTY: G8428: Current list of medications not documented as obtained, updated, or reviewed by the eligible professional, reason not given 54

55 PQRS Measure #134 Measure #134 (cont.) Screening for Clinical Depression and Follow-up This measure is to be reported a minimum of once per reporting period for all patients aged 12 years and older Description Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND if positive, a followup plan is documented on the date of the screen CPT code: ICD-10-CM codes: None specified for this measure G8431: Screening for clinical depression is documented as being positive AND a follow-up plan is documented G8510: Screening for clinical depression is documented as negative, a follow-up plan is not required G8433: Screening for clinical depression not documented, documentation stating the patient is not eligible THIS WILL RESULT IN NEGATIVE REPORTING AND WILL NOT AVOID THE PENALTY: G8940: Screening for clinical depression documented as positive, a follow-up plan not documented, documentation stating the patient is not eligible PQRS Measure #134 (cont.) Depression Screening Tools Include But Are Not Limited To: If you choose to report on this measure, check with your state licensure law to ensure that it is within the scope of practice for audiologists in your state If you select this measure for reporting, you will report: Whether or not the patient was screened for depression using a standardized tool (PHQ9, BDI or BDI-II, CES-D, DEPS, DADS, GDS, PRIME MD-PHQ2, PHQ-A, and BDI-PC) AND a follow-up plan was suggested Patient Health Questionnaire (PHQ-9) Beck Depression Inventory (BDI or BDI-II) Center for Epidemiologic Studies Depression Scale (CES-D) Depression Scale (DEPS) Duke Anxiety-Depression Scale (DADS) Geriatric Depression Scale (GDS) Cornell Scale Screening PRIME MD-PHQ2 Clinical Example for #134 New for 2016! 67 year old male referred by PCP for an audiologic and tinnitus assessment Chief complaint is tinnitus x 6 months Depression screening performed routinely by this practice CPT codes performed: 92557, and ICD-9 code: H93.13 (bilateral tinnitus) G code: G8431 (screening for clinical depression is documented as being positive AND a follow-up plan is documented) Measure #154 Falls: Risk Assessment Part of a two part measure (#155) Report once/calendar year if you perform CPT codes 92540, 92541, 92542, and/or To report on those patients who have had 2 or more falls in the past year or any fall resulting in an injury in the past year Numerator: Patients who had a risk assessment for falls completed within 12 months Fall: A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force. Injury: an event that results in the need for medical attention 55

56 Facts PQRS Measure #154: Falls Risk Assessment Falls are the leading cause of injury and deaths among older people, likely to grow In every second of every day, an older American falls In 2014, 29 million falls, 7 million injuries Fractures, head injuries, lacerations CDC says Medicare costs for falls: $31 billion Comprised of balance/gait AND one or more of the following: Balance/gait assessment: Get Up and Go Tanetti Demo videos are on the AQC website (R. Gans, PhD) Berg Postural blood pressure (supine, standing) Vision assessment (Snellen or referral for assessment) Home fall hazards assessment (can include referral for evaluation) Medications assessment (whether current meds may or may not contribute to falls) And documentation on whether medications are a contributing factor or not to falls within the past 12 months PQRS Measure #154 (cont.) Measure #154 (cont.) Patient reports no falls or only 1 fall without injury in the past year You perform 92540, 92541, and/or You must report CPT code 1101F Patient screened for future fall risk; documentation of no falls in the past year or only one fall without injury in the past year If patient reports 2 or more falls in the past 12 months or 1 fall with an injury AND risk assessment not performed for medical reasons (patient is not ambulatory, bedridden, immobile, confined to wheelchair) and you ve performed 92540, 92541, and/or 92548: Code 3288F with 1P AND 1100F 3288F with 1P is falls risk assessment documented 1P is also used to report documented circumstances that exclude patients (not ambulatory, bed ridden, etc.) AND 1100F is patient screened for future falls risk and documentation of 2 or more falls or any fall with injury in the past year Must also perform and report #155, Falls Risk Plan of Care Measure #154 (cont.) Measure #154 (cont.) If patient has 2 or more falls in the past 12 months OR 1 fall with an injury: And you performed 92540, 92541, and/or Perform standardized scale, review and document whether current medications may or may not be contributing to falls, dizziness, imbalance or vertigo When warranted, refer for: Postural blood pressure (supine, standing) Vision assessment (Snellen or referral for assessment) Home fall hazards assessment (can include referral for evaluation)and/or Medication review Code 3288F and 1100F Perform and report on Measure #155, falls risk plan of care 3288F with 1P is falls risk assessment documented 1P is also used to report documented circumstances that exclude patients (not ambulatory, bed ridden, etc.) AND 1100F is patient screened for future falls risk and documentation of 2 or more falls or any fall with injury in the past year 56

57 Measure #154 (cont.) Measure #154 (cont.) THIS WILL RESULT IN NEGATIVE REPORTING AND WILL NOT AVOID THE PENALTY: If falls status is not documented and you performed CPT codes 92540, 92541, and/or CPT code 1101F with 8P (no documentation of falls status) THIS WILL RESULT IN NEGATIVE REPORTING AND WILL NOT AVOID THE PENALTY: Risk assessment for falls not complete, reason not otherwise specified 3288F-8P AND 1100F PQRS Measure #155: Falls: Plan of Care Plan of Care (#155) This measure should be reported if 1100F is submitted for Measure #154. Also report even if a falls risk assessment was not performed if you performed CPT codes 92540, 92541, and/or F: Patient screened for future falls risk; documentation of two or more falls in the past year or any fall with injury in the past year Reported once/reporting period for those age > 65 years on date of encounter AND when 1100F is reported for #154 Must be reported with 0518F: Falls plan of care documented Plan of care must include: Consideration of Vitamin D supplementation was advised or considered or documentation that patient was referred to his/her physician for vitamin D supplementation advice Balance, strength and gait training Document that these were provided OR a referral was made to an exercise program that includes at least one of these components OR referral to physical therapy; can include referral for VRT and/or providing it in your practice Plan of Care (cont.) Example of a patient reporting dizziness OR 0518F with 1P: Documentation of medical reason(s) for no plan of care for falls (ie, patient is not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound, dependent on helper pushing wheelchair, independent in wheelchair or minimal help in wheelchair) (meets exclusion criteria) OR THIS WILL RESULT IN NEGATIVE REPORTING AND WILL NOT AVOID THE PENALTY: 0518F with 8P: Plan of care not documented, reason not otherwise specified Perform appropriate vestibular tests Report on the following measures: #130 (medications) (92540 not included) #154 (falls risk screening) #155 (falls risk plan of care) #226 (tobacco use and intervention) (if you did 92540) #261 (acute or chronic dizziness if ICD-10-CM codes are R42, H81.10, H81.11, H81.12 or H81.13) The claim form may have up to 5 different G or CPT II codes with these CPT test codes 57

58 PQRS Measure #226: Care and Screening: Tobacco Use: Screening and Cessation Intervention Measure #226 (cont.) Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling information if identified as a tobacco user Once/reporting period CPT codes: 92540, 92557, and/or for audiologists CPT codes: for SLPs No ICD-10-CMs are included Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user Tobacco use includes any type of tobacco Tobacco cessation intervention includes brief counseling (3 minutes or less) and/or pharma-cotherapy Measure #226 (cont.) Measure #226 (cont.) 4004F: Patient screened for tobacco use AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user OR 1036F: Current tobacco non-user (meets exclusion criteria) OR 4004F with 1P: Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reasons) THIS WILL RESULT IN NEGATIVE REPORTING AND WILL NOT AVOID THE PENALTY: OR 4004F with 8P: Tobacco screening OR tobacco cessation intervention not performed, reason not otherwise specified (patient is identified as a user, did not receive tobacco cessation counseling report) All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status or the use of other reminder systems such as chart stickers or computer prompts, significantly increase rates of clinical intervention. Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates. Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention. Measure #226 (cont.) The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking. PQRS Measure #261--Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness Denominator Patients aged birth and older AND CPT codes: 92540, , 92550, 92557, 92567, 92568, 92570, ICD-10 codes: R42(dizziness and giddiness) H81.10, H81.11, H81.12, H81.13 (BPPV codes) Report once per calendar year 58

59 PQRS Measure #261 (cont.) PQRS CPT Codes for Speech-Language Pathologists G8856: Referral to a physician for an otologic evaluation performed OR G8857: Patient is not eligible for the referral for otologic evaluation measure (e.g., pts who are already under the care of a physician for acute or chronic dizziness) (meets exclusion criteria) THIS WILL RESULT IN NEGATIVE REPORTING AND WILL NOT AVOID THE PENALTY: G8858: Referral to a physician for an otologic evaluation not performed, reason not specified #130 (medications): 92507, 92508, 92526, 92626, #131(pain): 92507, 92508, 92526, 92626, #226 (tobacco cessation): 92521, 92522, 92523, PQRS Measure #131 Pain Assessment and Follow-Up SLPs only Pain Standardized Tool Percentage of patients aged 18 and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present Report for each visit along with #130 No ICD-10-CM specificity CPT codes: 92507, 92508, and Report only if state licensure scope of practice allows for standardized screenings and referrals for pain Required to determine presence or absence of pain May include location, intensity, description and onset/duration Can include: Brief Pain Inventory (BPI) Faces Pain Scale (FPS McGill Pain Questionnaire (MPQ) Multidimensional Pain Inventory (MPI) Neuropathic Pain Scale (NPS) Numeric Rating Scale (NRS) Oswestry Disability Index (ODI) Roland Morris Disability Questionnaire (RMDQ) Verbal Descriptor Scale (VDS) Verbal Numeric Rating Scale (VNRS) Visual Analog Scale (VAS) Follow-Up Plan Not eligible if Documented outline of care for a positive pain assessment is required Must include: A planned f/u appointment or referral Notification to other care providers as applicable OR Indicate the initial treatment plan is still in effect May include pharmocologic and/or educational interventions Severe mental and/or physical incapacity where the person is unable to express themselves in a manner understood by others Patient is in an urgent or emergent situation and a delay in treatment would jeopardize the patient s health status 59

60 G Codes to use, with tool documented in chart Exclusions: G 8730 Pain assessment documented as positive using a standardized tool AND a follow-up plan is documented OR G8731 Pain assessment using a standardized tool is documented as negative, no follow-up plan required OR G8442 Pain assessment NOT documented as being performed, documentation the patient is not eligible for a pain assessment using a standardized tool OR G8939 Pain assessment documented as positive, followup plan not documented, documentation the patient is not eligible OR Performance Not Met: Other Codes for SLPs G8732 No documentation of pain assessment, reason not given G8509 Pain assessment documented as positive using a standardized too, follow-up plan not documented, reason not given THESE WILL RESULT IN NEGATIVE REPORTING AND WILL NOT AVOID THE PENALTY: G codes for functional limitation and status for: Swallowing Motor speech Spoken language comprehension Spoken language expression Attention Memory Voice Other SLP Functional Limitation Codes for functional limitation, current status at the time of the initial therapy/episode outset and reporting intervals Swallowing: G8996 Motor speech: G8999 Spoken language comprehension: G9159 Spoken language expression: G9162 Attention: G9165 Memory: G9168 Voice: G9171 Other SLP functional limitations: G9174 Codes for functional limitation, projected goal status at initial therapy treatment/onset and at discharge from therapy Swallowing: G8997 Motor speech: G9186 Spoken language comprehension: G9160 Spoken language expression: G9163 Attention: G9166 Memory: G9169 Voice: G9172 Other SLP functional limitations: G

Codes For Functional Limitation, Discharge Status At Discharge from therapy/end of reporting on limitation Tips: Swallowing: G8998 Motor speech: G9158 Spoken language comprehension: G9161 Spoken

Modifiers are required by the Centers for Medicare and Medicaid Services (CMS) with the use of all G-codes Can report National Outcomes Measurement System (NOMS), not required by CMS Severity rating

61 Codes For Functional Limitation, Discharge Status At Discharge from therapy/end of reporting on limitation Tips: Swallowing: G8998 Motor speech: G9158 Spoken language comprehension: G9161 Spoken language expression: G9164 Attention: G9167 Memory: G9170 Voice: G9173 Other SLP functional limitations: G9176 Use all 3 when there will not be an ongoing process Use 1 when it is an ongoing process Modifiers are required by the Centers for Medicare and Medicaid Services (CMS) with the use of all G-codes Can report National Outcomes Measurement System (NOMS), not required by CMS Severity rating scale (1-7) Impairment Limitation Restriction Modifiers (ASHA) What Do You Get From CMS? Monitor your Remittance Advice (EOB) summaries N620: This procedure code is not payable. It is for reporting/information purposes only. Indicates that the PQRS codes were received Does not guarantee that reporting was correct Check your quarterly reports SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. 61

CMS PQRS Resource- QualityNet Help Desk SlidesCarnival icons are editable shapes.

and access PQRI-IACS registration questions PQRI-IACS login issues Phone: 1-866-288-8912 TTY: 1-877-715-6222 Email: Qnetsupport@hcquis.

html To allow consumers to search for physicians and other health care professionals enrolled in the Medicare program (ACA).

Consumers can select providers based on robust and reliable quality of care data THIS INCLUDES YOUR PQRS REPORTING All those enrolled in PECOS are to be listed Check your own

62 CMS PQRS Resource- QualityNet Help Desk SlidesCarnival icons are editable shapes. Available Monday Friday; 7:00 AM 7:00 PM CT General CMS Physician Quality Reporting System and erx Incentive Program information Portal password issues Feedback report availability and access PQRI-IACS registration questions PQRI-IACS login issues Phone: TTY: CMS PQRS Webpages Physician Compare Assessment-Instruments/PQRS/index.html To allow consumers to search for physicians and other health care professionals enrolled in the Medicare program (ACA). The purpose of Physician Compare is to help consumers make informed choices about healthcare they receive through Medicare and to incentivize physicians to maximize performance Consumers can select providers based on robust and reliable quality of care data THIS INCLUDES YOUR PQRS REPORTING All those enrolled in PECOS are to be listed Check your own listing: Physician Compare (cont.) SlidesCarnival icons are editable shapes. Information currently provided: Medicare enrolled providers names, addresses, phone numbers, specialties, training, gender Languages spoken other than English If provider is accepting new Medicare patients and if they accept assignment Hospital affiliations Outcome measures reporting 62

63 2017 PQRS Measures SlidesCarnival icons are editable shapes.? MACRA, MIPS and APMs MIPS and APMs Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Different than the Affordable Care Act (2010) Ended the Sustainable Growth Rate (SGR) Historically was more than a dozen temporary fixes New framework for rewarding health care providers for giving better care, not just more care Combing existing quality reporting programs into one Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA- MIPS-and-APMs.html Merit-Based Incentive Payment System (MIPS) OR Alternative Payment Models (APM) Will combine PQRS, merit based programs and EHR Measured on quality, resource use, clinical practice improvement, management of certified EHR technology Moving away from fee-for-service and to positive, negative or neutral adjustments in payment Moving toward low-cost, high quality patient care MIPS What We Do Know Payment to be based on: Quality Clinical practice improvement Incentives for care coordination, patient opportunities for greater access Advancing care information Electronic Healthcare Records Resource use Performance measurement for specific measures Point system-highest points for higher quality care Awaiting final rule, no known date of release On or around November 1 st with the MPFS? Impact to audiologists likely won t be until at least 2019 as we are one of several professions excluded for 2019 Were SLPs omitted from the list?? PT and OT are noted PQRS as we now know it will likely be sunsetted in 2017 Continue to do what you are doing! It s good patient care and best practices Medications (both), tobacco(both), balance and tinnitus patients 63

64 CMS 1500 form CMS 1500 form (cont.) The National Uniform Claim Committee (NUCC) Voluntary organization, chaired by the AMA CMS partners with NUCC Revision due to changes: Meets requirements of several initiatives ICD-10 changes Need more room for longer codes Added 8 additional lines (total of 12 diagnosis codes) Changed from numeric to alphabetic (A-L) Removed the period within the code lines Need to indicate referring (DN), ordering (DK) or supervising (DQ) provider in box 17 Changed form date from 08/05 to 02/ rectangular symbol now has a QR (Quick Response Code) Other form changes: TRICARE CHAMPUS changed to TRICARE Social Security Number changed to ID# Box 19 changed to additional claim information Other changes Balance due is Rsvd for NUCC Use CMS 1500 form timeline Claim Form As of April 1, 2014: Payers receive and process paper claims submitted ONLY on the revised version (02/12) claim form Consult with your practice management system vendor Forms may be ordered here: 1500form@tfpdate.com ( , ext ) ( ) Lists the CPT(s), ICD(s) and HCPCS codes and demonstrates their interaction: What you performed (CPT) Diagnosis results (ICD) Resulting recommendations if product (HCPCS) Ties the coding systems together What Goes Where? What Goes Where (cont.) Boxes 1-16 Patient information Box 17 Referring Provider Include their NPI Include DN (referring provider) or DK (ordering provider) Box 19 Can include need denial from Medicare for secondary to pay Box 21 ICD-10-CM codes Box 24 (A-J) A: Date of service B: Place of service 11 Office 12 Home 31 Skilled Nursing Facility 32 Nursing Facility 34 Hospice 64

What Goes Where (cont.) What Goes Where (cont.

pointers Corresponds to A-L in the ICD-10-CM boxes F: Fees

codes, earmolds, earmold impressions) J: Your National

Identification Number (TIN) Box 26: Patient account

or no Box 28: Total charge Box 29: Amount patient paid Box

name, address, phone, NPI Standardized Billing Form: The

Standardized Billing Form: The Interactive CMS 1500

palmettogba.com/internet/cms1500.nsf/cms1500.

htm Claims must be submitted electronically Submit an

include: A physician, practitioner, or supplier that has

Claims filed later than one calendar year after date of

65 What Goes Where (cont.) What Goes Where (cont.) D: CPT/HCPCS/PQRS codes and modifiers E: Diagnosis pointers Corresponds to A-L in the ICD-10-CM boxes F: Fees G: Units (most will be 1 with the exception of time based codes, earmolds, earmold impressions) J: Your National Provider Identifier (NPI) Box 25: Federal Tax Identification Number (TIN) Box 26: Patient account number, if one is assigned Box 27: Accept assignment Yes or no Box 28: Total charge Box 29: Amount patient paid Box 32: Facility name, location, NPI number Box 33: Provider name, address, phone, NPI Standardized Billing Form: The CMS 1500 SlidesCarnival icons are editable shapes. Standardized Billing Form: The CMS 1500 SlidesCarnival icons are editable shapes. Interactive CMS 1500 Instructions Medicare Claims Submission ml# Claims must be submitted electronically Submit an Electronic Data Interchange (EDI) form A few exceptions include: A physician, practitioner, or supplier that has fewer than 10 Full-Time Equivalent (FTE) employees. Claims filed later than one calendar year after date of service will be denied No appeal process Patient cannot be billed Image: 65

66 Medicare Claims Submission (cont.) Effective 1/1/15, to replace -59: When you furnish covered services to Medicare beneficiaries, you are required to submit claims for your services and cannot charge beneficiaries for completing or filing Medicare claim. - Learning-Network- MLN/MLNProducts/Downloads/MedicareClaimSubmissionGui delines-icn pdf XE Separate Encounter: A service that is performed under the same billing provider NPI on the same date of service, but is distinct because it is a separate encounter for the patient. XS Separate Structure: A service that is performed under the same billing provider NPI on the same date of service, but on a different structure or organ. XP Separate Practitioner: A service that is performed under the same billing provider NPI on the same date of service, but is distinct because it is performed by a different individual provider. XU Unusual Non-Overlapping Service: A service that is performed under the same billing provider NPI on the same date of service, but the procedure does not overlap the usual components of the main service performed. Medicare Modifiers (cont.) Medicaid None truly are applicable CMS guidance is to continue to use the -59 modifier Use when you file a claim for 1-3 of the codes that are included in (basic vestibular evaluation): The individual state agency that provides services for low income residents Federal government matches state funds Differs in coverage from state to state Hearing and audiology services included Early and Periodic Screening, Diagnosis and Treatment (EPSDT) regulations allow for mandatory coverage of health care services, including hearing services, birth to age 21 Medicaid Prior to enrolling in your state s Medicaid program, need to know: If you can sustain your practice with providing services to this population Lowest reimbursement of any payer Can t ration services-you are either in or out Know coverage and billing processes They are unlike any other payer Rates and requirements Diagnostics and hearing aid dispensing Break! 66

67 Documentation-Why Is It Important? Documentation A chart is a legal document Provides continuity of care between health care professionals Requirement of third party payers Peer Review Need to explain and interpret test results Not all readers will be audiologists Essential in daily practice Audits Electronic Health Care records (EHR) More vital for ICD-10 s Is addressed in the Academy s COE (5e) Individuals shall maintain accurate documentation of services rendered according to accepted medical, legal and professional standards and requirements. What should be included? What else? Demographic information Patient s name Date of birth Contact information Insurance card Photocopy front and back (need address) Driver s license Medical Identity Theft Collections If required by a third party payer, include the referring provider If not referred, note that the patient self-referred Medicare physician orders: On the physician s letterhead or prescription pad May want to avoid referral pads with your practice name so as not to appear that the order was solicited Check with Noridian for their guidance on the use of referral pads Documentation (cont.) Chart Notes: Sign and date the audiogram and chart notes Must provide user instructional brochure for hearing aids and note it in the record Must obtain medical clearance for hearing aids or provide waiver If I can t code your encounter form from your documentation, then your documentation is inadequate. Kyle Dennis, personal If it isn t in the chart, it didn t happen Need to document all that patient relays to you SOAP outline Need to explain and interpret test results Don t assume anyone other than an audiologist understands what it means 67

SOAP Hard Copy Guidance Subjective findings History Objective finding Physical exam Testing Assessment Creating a differential diagnosis or diagnoses Plan Recommendations for patient based on the

68 SOAP Hard Copy Guidance Subjective findings History Objective finding Physical exam Testing Assessment Creating a differential diagnosis or diagnoses Plan Recommendations for patient based on the above Referrals to others No sticky notes! Everything needs to be secured with the patient s name and date If err, strike through with one single line No scribbling or liquid paper All Personal Health Information (PHI) should be shredded Sticky notes too if they have PHI Documentation Documentation A chart is a legal document Can be subpoenaed Provides continuity of care between health care professionals Quality Assessment Payer requirement Need to explain and interpret tests results Don t assume a non-audiologist provider understands anything about any diagnostic test or treatment What should be included? And? Demographic information Patient s name Address Date of birth Contact information Insurance card Photocopy front and back (need address) Driver s license Medical Identity Theft Reason for the visit Case history Surgeries Medications, past and present Herbals, over-the-counter meds Occupational noise exposure Recreational noise exposure 68

69 More More HIPAA forms Notice of Privacy Practices (NPP) Case history Adult Familial hearing loss Age of onset, syndromes? Treatment plan Surgeries Amplification Other Pediatric: History: Prenatal Delivery Familial hearing loss Developmental milestones What else? And? Who is the referring professional if required by a third party payer? Medicare physician referrals: On the physician s letterhead or prescription pad Not to have the appearance that it was solicited by you May want to avoid referral pads with your practice name Contact your Medicare Administrative Contractor (MAC) for guidance Get it in writing Reason for the visit Include other diseases that may impact hearing and balance Case history Family history of ear disease, hearing loss and other hereditary diseases/syndromes Surgeries Medications, past and present Prescriptions, herbals, over-the-counter meds Occupational noise exposure Recreational noise exposure Case History (cont.) More Case history Adult Familial hearing loss Age of onset, syndromes? Treatment plan Surgeries? Amplification? Notice of Privacy Practices (NPP) Review of systems Pediatric: History: Prenatal Delivery Family 69

70 Chart Notes: SOAP If it isn t in the chart, it didn t happen Need to document what the patient communicates to you Many utilize the SOAP outline Subjective, objective, assessment and plan Subjective findings History Objective finding Physical exam Otoscopy Otoscopy pre and post earmold impression with notes Testing Assessment Puzzle piecing Plan Recommendations for patient based on the above Referrals to others Hard Copy Guidance Electronic Health Care Records (EHR/EMR) If err, strike through with one single line Initial with your three initials Do not use white out Do not scribble Enter all applicable information for that particular date of service Date and possibly time stamped Some systems disallow re-entry for that time period May have to add an addendum Some systems have templates for: Audiograms Tympanometry Real ear measures Outcome measures If there are no templates, they ll need to be scanned into the patient s record Bundling vs. Itemization: Bundling vs. Itemization (cont.) Bundling vs. itemization Likely to optimize reimbursement with third party payers Gives the insurance company the choice to bundle Transparency (HLAA) Bundling One payment, one code Does not decipher what is service and what is product Itemization (detaches service from product) Separate itemization of all fees: Hearing aid(s) Dispensing fee(s) Orientation fee Conformity evaluation Earmold(s) Earmold impression(s) Batteries Extended service or warranty packages Office visits? 70

71 Question: I currently bundle my fees Tidbits Yes No Must know your hourly rate HAVE TO KNOW WHAT YOUR EXPENSES ARE Need to know with each separate contract what you can (or can t afford) to loose Don t make decisions out of fear, but out of a thorough evaluation of what your practice needs to survive May need to restrict product offerings May need to refer elsewhere Are insurance waivers allowed Denial and termination processes Durable Medical Equipment (DME) DME Hearing aids are not considered DME by Medicare Hearing aids may be considered DME by third party payers and/or your state s Medicaid agency As long as it is not contractually excluded, a patient should expect to pay for services If you are not contracted for DME/hearing aids that you are not held to the payer s fee schedule for DME/hearing aids Next steps (cont.) Waivers Medical necessity vs. patient care protocols Purchase agreement State licensure law requirements Itemization may not be allowed by state licensure Specific tests (e.g., MCLs, UCLs, bone conduction at 250 Hz) may be required in state licensure law(s) when dispensing amplification Patient s acknowledgement of their financial responsibility for fees not paid by their insurance benefit, if not contractually excluded Have patient sign at the time of providing services Time of patient education Itemize CPT/HCPCS codes to be utilized and patient out of pocket cost estimate Original retained in chart, copy to patient Not the same as the ABN (Medicare only) 71

Waivers (cont.) SlidesCarnival icons are editable shapes. Do your payers provide their own? Will they allow one that your office creates?

for Third Party Payers Establishing Hourly Rate Know your hourly rate Don t make decisions out of fear Need to know with each separate contract what you can (or can t afford) to loose Some will pay

won t allow you to bill the patient for the difference between the allowable and the payment amount May need to restrict product offerings (AGX 3 instead of an AGX 9) Ask if insurance waivers are

) Number of providers in the practice (2?) Multiply the hours/week/year by the number of providers (49 x 2 = 98) x 30 = 2940 Hourly Rate Calculation (cont.

72 Waivers (cont.) SlidesCarnival icons are editable shapes. Do your payers provide their own? Will they allow one that your office creates? Should include: Patient s name Date How much is their responsibility and for what They must understand this is beyond their benefit and their EOB may have the benefit stating they owe zero Itemizing for Third Party Payers Establishing Hourly Rate Know your hourly rate Don t make decisions out of fear Need to know with each separate contract what you can (or can t afford) to loose Some will pay 50% or 60% of what is billed Need to charge your usual and customary fees to everyone in order to sustain this rate; can offer cash discounts to private pay patients with caution and a policy Some won t allow you to bill the patient for the difference between the allowable and the payment amount May need to restrict product offerings (AGX 3 instead of an AGX 9) Ask if insurance waivers are allowed if patient wants to go beyond their benefit Be aware of the denial and termination processes How many hours/week? (30?) Direct patient care time only Weeks/year that services are provided (49?) Number of providers in the practice (2?) Multiply the hours/week/year by the number of providers (49 x 2 = 98) x 30 = 2940 Hourly Rate Calculation (cont.) Includes: Does not include: Salary/benefits Overhead Rent, equipment, utilities, marketing, etc. Hourly rate = Annual expenses 2940 Cost of goods (COG): Hearing aids Ear molds Batteries ALDs Hearing aid accessories To Determine Break-Even Hourly Rate and Profit Margin Total annual expenses COG annual contact hours (break-even point) $XXX.xx COG 2940 = YYY.yy Total annual expenses COG + desired profit annual contact hours $XXX.xx COG + DP 2940 = YYY.yy 72

73 Next Steps: Next Steps: Assign fees for each professional service procedure based on your hourly rate/profit goal Load payer allowables into your management system Compare amounts paid with contracted fees Don t assume the payer s amount is correct Purchase agreement State licensure law requirements Itemization may not be allowed by state licensure Specific tests (e.g., MCLs, UCLs, bone conduction at 250 Hz) may be required in state licensure law(s) when dispensing amplification Healthcare Common Procedure Coding System (HCPCS) HCPCS Codes Some services Hearing aid devices and supplies Cochlear implant codes (non-stimulation and mapping) Osseo-integrated codes Services V5008 Hearing screening V5010 (Assessment for hearing aid) May be required by Medicaid V5011 (Fitting/orientation/checking of hearing aid) V5014 (Repair/modification of a hearing aid) V5020 (Conformity evaluation) Real ear measures S0618 (Audiometry for hearing aid evaluation to determine the level and degree of hearing loss) Dispensing fees applicable to the type of device Supplies: Hearing aids Earmold impressions and earmolds Batteries Assistive Listening Devices Cochlear Implant Codes (cont.) Osseointegrated Device Codes L8622 Alkaline battery for use with CI device, any size, replacement, each L8623 Lithium ion battery for use w/ CI device speech processor; other than ear level, replacement, each L8624 Lithium ion battery for use with CI device speech processor, ear level, replacement, each L8627 CI, external speech processor, component, replacement L8628 CI, external controller component, replacement L8629 Transmitting coil and cable, integrated, for use with CI device, replacement L8690 Auditory osseointegrated device, includes all internal and external components L8691 Auditory osseointegrated device, external sound processor replacement L8692 Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment L8693 Auditory osseointegrated device abutment, any length, replacement only L9900 Orthotic and prosthetic supply, accessory, and/or service component of another Fitting: V5299 Hearing service, miscellaneous OR L8699 Auditory osseointegrated device, includes all internal and external components 73

Hearing Aid Modifiers Waivers May be payer dependent RT indicates right side (ear) LT indicates left side (ear) May need to bill each service and device with monaural codes with modifier for each ear

74 Hearing Aid Modifiers Waivers May be payer dependent RT indicates right side (ear) LT indicates left side (ear) May need to bill each service and device with monaural codes with modifier for each ear separately instead of binaural codes Serves as the patient s acknowledgement of their personal financial responsibility that will not be paid by their insurance benefit Patient should sign at the time of service Time of patient education Itemize CPT/HCPCS codes to be utilized Retain the original, give a copy to patient Not the same as the ABN Does the payer recognize S1001, Deluxe item, patient notified? Waivers (cont.) Hearing Aid Evaluation options: Do your payers provide their own? Will they allow one that your office creates? Should include: Patient s name Date How much is their responsibility and for what They must understand this is beyond their benefit and their EOB may have the benefit stating they owe zero S0618 Audiometry for hearing aid evaluation to determine the level and degree of hearing loss OR V5010 Assessment for hearing aid OR Hearing aid examination and selection, monaural OR Hearing aid examination and selection, binaural Example: Monaural BTE SlidesCarnival icons are editable shapes. HAE V5011 Fitting/orientation/checking of hearing aid V5020 Conformity Evaluation V5241 Dispensing fee, monaural hearing aid, any type V5257 Hearing aid, digital, monaural, BTE V5264 Earmold/insert, not disposable, any type (1 unit) V5266 Battery V5275 Earmold impression, each V5299 Hearing service, miscellaneous (extended warranty packages, for example) Typically not reimbursed by third party payers 74

75 Monaural BTE (example) (Hearing aid examination and selection, monaural), or V5010 (Assessment for hearing aid). Your choice of the code may be payer dependent. V5011 Fitting/orientation/checking of hearing aid V5020 Conformity Evaluation V5241 Dispensing fee, monaural hearing aid, any type V5257 Hearing aid, digital, monaural, BTE V5264 Earmold/insert, not disposable, any type (1 unit) V5266 Battery V5275 Earmold impression, each V5299 Hearing service, miscellaneous (extended warranty packages, for example) Example: Binaural RICs HAE option V5011 Fitting/orientation/checking of hearing aid V5020 Conformity Evaluation V5160 Dispensing fee, binaural V5261 Hearing aid, digital, binaural, BTE V5266 Battery V5299 Hearing service, miscellaneous (extended warranty packages, for example) For receiver in the canal (RIC) technology, the receiver could be billed as V5267, hearing aid supplies/accessories. Binaural BTEs With Two Earmolds Binaural Hearing Aids When Payer Requires LT/RT modifiers HAE option V5011 Fitting/orientation/checking of hearing aid V5020 Conformity Evaluation V5160 Dispensing fee, binaural V5261 Hearing aid, digital, binaural, BTE V5264 Ear mold/insert, not disposable, any type V5266 Battery V5275 Ear impression, each V5299 Hearing service, miscellaneous (extended warranty packages, for example) HAE option V5011-RT Fitting/orientation/checking of hearing aid V5011-LT Fitting/orientation/checking of hearing aid V5020-RT Conformity evaluation V5020-LT Conformity evaluation V5257-RT Hearing aid, digital, monaural, BTE V5257-LT Hearing aid, digital, monaural, BTE V5241-RT Dispensing fee, monaural hearing aid, any type V5241-LT Dispensing fee, monaural hearing aid, any type V5264-RT Earmold/insert, not disposable, any type V5264-LT Earmold/insert, not disposable, any type V5275-RT Earmold impression, each V5275-LT Earmold impression, each V5267-RT Hearing aid supplies/accessories, if indicated V5267-LT Hearing aid supplies/accessories, if indicated V5266-RT Battery for use In hearing device V5266-LT Battery for use In hearing device BICROS Billing: BICROS (example) When billing for CROS or BICROS devices: Check with the payer as some don t recognize what a (BI)CROS device is May want to obtain prior authorization to ensure that you will be paid for the entire device and for corresponding services Bill the (BI)CROS codes and if not paid fairly, then appeal with an explanation HAE V5011 Fitting/orientation/checking of hearing aid V5020 Conformity Evaluation V5220 Hearing aid, BICROS, behind the ear V5240 Dispensing fee, BICROS V5266 Battery for use In hearing device V5264 Earmold/insert, not disposable, any type (This would be filed with the number of earmolds utilized) V5275 Earmold impression, each (This will need to be filed with the number of EMIs taken) V5299 Hearing service, miscellaneous (extended warranty packages, for example) 75

Another option for BICROS: HAE V5011 Fitting/orientation/checking of hearing aid V5020 Conformity Evaluation V5241 Dispensing fee, monaural hearing aid, any type V5257 Hearing aid, digital, monaural,

V5275 Earmold impression, each (This will need to be filed with 2 units for 2 earmold impresssions) V5299 Hearing service, miscellaneous (extended warranty packages, for example) Typically not

Itemizing binaural hearing aids S0618 Audiometry for hearing aid evaluation to determine the level and degree of hearing loss V5010 Assessment for hearing aid 92590 Hearing aid examination and

76 Another option for BICROS: HAE V5011 Fitting/orientation/checking of hearing aid V5020 Conformity Evaluation V5241 Dispensing fee, monaural hearing aid, any type V5257 Hearing aid, digital, monaural, BTE V5264 Earmold/insert, not disposable, any type (1 unit) (This will need to be filed with 2 units for 2 earmolds) V5266 Battery V5267 Hearing aid supplies/accessories (for offside microphone) V5275 Earmold impression, each (This will need to be filed with 2 units for 2 earmold impresssions) V5299 Hearing service, miscellaneous (extended warranty packages, for example) Typically not reimbursed by third party payers SlidesCarnival icons are editable shapes. Itemizing binaural hearing aids S0618 Audiometry for hearing aid evaluation to determine the level and degree of hearing loss V5010 Assessment for hearing aid Hearing aid examination and selection, monaural Hearing aid examination and selection, binaural Binaural BTEs, with earmolds (Hearing aid examination and selection, binaural), or V5010 (Assessment for hearing aid). Your choice of the code may be payer dependent. V5011 Fitting/orientation/checking of hearing aid V5020 Conformity Evaluation V5160 Dispensing fee, binaural V5261 Hearing aid, digital, binaural, BTE V5264 Earmold/insert, not disposable, any type (This will need to be filed with 2 units for 2 earmolds) V5266 Battery for use In hearing device V5275 Earmold impression, each (This will need to be filed with 2 units for 2 earmold impressions) V5299 Hearing service, miscellaneous (extended warranty packages, for example) *For receiver in the canal (RIC) technology, the receiver could be billed as V5267, hearing aid supplies/accessories. Question: Resources (cont.) I bill a BICROS hearing aid: 1. With the BICROS code(s) 2. With the BICROS and hearing aid code(s) 3. Depends ages/medicare_faq.aspx ocuments/201105_cms_1500_form_at_a_glance.pdf ocuments/enrollmentoptions4medicare.pdf 76

SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes.

Anti-Kickback Statutes Safe Harbors Stark Laws Medicare requirements Health Information Portability Accountability Act (HIPAA) Occupational Safety and Health Act (OSHA) American Disabilities Act

difference between what was billed and what is allowed What are the allowed charges? Co-pays? (specific dollar amount) Are required to be collected Co-insurance?

) Request fee schedule Monitor it annually Review prior to signing contract In network vs out of network Be aware of the: Credentialing process (Audigy does this for you!

77 SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. Contracting Tidbits Contracting Questions: Obtain legal counsel to review contracts Well-versed in applicable federal and state health care regulations Must be in compliance with: Federal Statutes Anti-Kickback Statutes Safe Harbors Stark Laws Medicare requirements Health Information Portability Accountability Act (HIPAA) Occupational Safety and Health Act (OSHA) American Disabilities Act (ADA) State Statutes Some may be more stringent that the federal regulations Balance billing definition Many think it is the difference between what was billed and what was paid It is the difference between what was billed and what is allowed What are the allowed charges? Co-pays? (specific dollar amount) Are required to be collected Co-insurance? (percentage) Deductibles are required to be collected Contracting Questions (cont.) Contracting Questions (cont.) Request fee schedule Monitor it annually Review prior to signing contract In network vs out of network Be aware of the: Credentialing process (Audigy does this for you!) Denial process Termination process Need to know your expenses/costs Some of these plans actually can cost YOU money Low reimbursement, write offs Can the patient upgrade beyond their benefit to greater levels of technology? Non-covered benefit Review contracts and fees every 6-12 months Can make changes without notification (evergreening) Compare Explanation of Benefits (EOBs) to payments Payers do make errors Don t want to write off more than what you have to 77

78 Contracting More Considerations Need to know if you can afford to be a provider: Overhead costs, practice expenses? Number of patients you can expect? Do you have to give something(s) away? What may be a beneficial arrangement for the practice down the street may not be for you Contracting must be data-driven, not fear driven Negotiated rate Differences between payers Verification process A requirement with EVERY patient Complete before hearing aid evaluation Ability of patient cost sharing? The MOST important question Under what circumstances? Furthermore More tidbits Fee schedule Obtain one before signing on the dotted line! Ask for updates on a minimum of an annual basis Do not submit an invoice unless hearing aid benefit is invoice + cost When must claim be filed? When must payment be made? Prompt payment state regulations Does the discount you offer for diagnostics apply to hearing aids/assistive listening devices? Even More Considerations Steps to Contracting How much professional liability are you required to carry? $1million/$3 million What are you required to meet with hearing instruments: Free hearing evaluations? Free batteries? Free rechecks? If so, for how long? Level of technology? Required number of visits? Request Information Complete Application and Credentialing Process Will need a License, NPI and Tax ID 78

Provider Insurance Credentialing Provider Insurance Credentialing Provider Enrollment Process of applying for inclusion to a health insurance s provider network Two step process for commercial

?? Insurance carrier specific application Information needed for credentialing: Personal Demographics State license info Service, billing and correspondence addresses Education information Employment

79 Provider Insurance Credentialing Provider Insurance Credentialing Provider Enrollment Process of applying for inclusion to a health insurance s provider network Two step process for commercial insurances: Credentialing Contracting Credentialing can be completed multiple ways On-line (CAQH, OneHealthPort, etc.) State specific application??? Insurance carrier specific application Information needed for credentialing: Personal Demographics State license info Service, billing and correspondence addresses Education information Employment history Professional liability Peer reference (at least 3) Provider Insurance Credentialing Provider Insurance Credentialing Necessary documents: State license Diploma for highest level of education Professional liability face sheet W-9 Driver s license On-line credentialing CAQH (Council for Affordable Quality Healthcare) All your information is entered and stored for commercial insurances to access Need to update documents and re-attest every quarter to keep information up to date Failure to update documents or re-attest will cause you to be terminated from any insurance that accesses CAQH Provider Insurance Credentialing Provider Insurance Credentialing Paper application submission Re-credentialing happens every 2-3 years Review, updating and adding/deleting information Updated documents Failure to re-credential will result in termination If terminated, you will need to go through the initial credentialing process again and a new effective date will be issued. Initial credentialing Can take days to complete Once complete, contracting can take an additional days Most commercial insurances do not back-date effective dates Effective dates are issued once both steps are completed 79

Denial/Appeal How to File an Appeal When to appeal?

Letter of appeal Include patient name, date of birth, copy of insurance card and a copy of the Explanation of Benefits (EOB) Letter addressing the reason for appeal Didn t meet the patient s benefit?

) Tru Hearing Blue Cross/Blue Shield Promotes that they have more than 3800 qualified TruHearing Providers Select or Choice plans Dispensing fee is typically $375/ear or $600/ear, depending on

pay devices, $50 after first year per visit If not contracted directly with TruHearing, you can proceed as you choose, but contact your local BC/BS representative when verifying benefits American

80 Denial/Appeal How to File an Appeal When to appeal? When your reimbursement was not as patient s contract stipulated Need to monitor There is a contract with the patient and their insurance company There is a contract with the patient s payer and you Letter of appeal Include patient name, date of birth, copy of insurance card and a copy of the Explanation of Benefits (EOB) Letter addressing the reason for appeal Didn t meet the patient s benefit? Insurance companies do make errors Insurance Networks Insurance Networks (cont.) Tru Hearing Blue Cross/Blue Shield Promotes that they have more than 3800 qualified TruHearing Providers Select or Choice plans Dispensing fee is typically $375/ear or $600/ear, depending on technology, 3 visits in the first year at no charge; need to verify Batteries first year, 45 day trial period If contracted with with TruHearing, you are reimbursed $75 for an evaluation fee, they pay devices, $50 after first year per visit If not contracted directly with TruHearing, you can proceed as you choose, but contact your local BC/BS representative when verifying benefits American Hearing Benefits (AHB) Part of AudioNet America which includes AHB, HearUSA and Hearing Life/AHAA Starkey devices via AudioNet America for UAW Ford and GM plans After 6 months, office visits can be filed for $20/visit EPIC Hearing healthcare benefit plan Partners with Phonak (and Lyric), Unitron, GN Resound, Starkey, Widex, Siemens, Oticon Contractor for services (e.g., UHC) Insurance Networks (cont.) Amplifon (formerly HearPO) Cigna Approximately a $2800 benefit Dispensing fees, testing, free batteries for 2 years, 3 year repair, loss and damage warranty 60 day trial period Federal Regulations Impacting Audiology and Speech- Language Pathology 80

for purchasing, leasing, or ordering (or recommending the purchase, lease, or ordering) of any item or service reimbursable in whole or in part under a federal health care program.

81 Anti-Kickback Statutes (42 U.S.C. 1320a-7b(b)) AKS (cont.) Applies to Medicare, Medicaid and other federal payers who knowingly and willfully solicits or receives any remuneration, directly or indirectly, overtly or covertly, in cash or in kind, in return for purchasing, leasing, or ordering (or recommending the purchase, lease, or ordering) of any item or service reimbursable in whole or in part under a federal health care program. Kickbacks in health care result in: Overutilization Increased costs to Medicare Unfair competition for those unwilling to pay kickbacks Corruption of medical decision-making AKS (cont.) Penalties Steep penalties, enforced by the Office of the Inspector General Criminal (felony): Up to 5 years in prison AND Fines up to $25,000/violation and treble charges (3 times the amount of remuneration offered, paid, solicited or received) Civil: Up to $50,000 and 3 times the kickback (treble damages) Exclusion from participation in federal health care programs AKS (cont.) AKS (cont.) Applies to: Medicare Any procedures Cochlear Implants Osseo-integrated devices Medicaid Tricare Federal Employees Health Benefit Policy (FEHBP) Vocational Rehabilitation Veterans Affairs (VA) Outsourcing services to public sector providers Forgiving a co-pay may be a violation, if a routine practice Need to attempt to collect co-pays and deductibles unless you have proof of the patient s inability to pay Good faith effort Legal to provide discounted services to uninsured people Professional discounts may be a violation 81

AKS (cont.) AKS (cont.) Illegal to submit claims you know are false/fraudulent No specific intent to defraud is required http://oig.hhs.gov/compliance/physician-education/01laws.

violation or specific intent to commit a violation is not necessary for conviction under the statute Government must still prove intention of law violation, but no longer has to prove the intent to

, Pub. L. No. 111-148, 6402(f)(2), 124 Stat 119 (2010) Stark Law (42 U.S.C.

a physician has a financial relationship, either ownership or a compensation arrangement, with the entity A physician may not refer Medicare patients for designated health services to an entity with

82 AKS (cont.) AKS (cont.) Illegal to submit claims you know are false/fraudulent No specific intent to defraud is required Government does not need to prove patient harm or financial loss to the programs to show that a provider violated the AKS Even if medical necessity has been met Actual knowledge of an AKS violation or specific intent to commit a violation is not necessary for conviction under the statute Government must still prove intention of law violation, but no longer has to prove the intent to violate the AKS itself PPACA, Pub. L. No , 6402(f)(2), 124 Stat 119 (2010) Stark Law (42 U.S.C. 1395nn) Stark Law Stark prohibits self-referrals for the provision of Designated Health Services (DHS) and all claims for federal reimbursement for such services furnished pursuant to a referral, if a physician has a financial relationship, either ownership or a compensation arrangement, with the entity A physician may not refer Medicare patients for designated health services to an entity with which the physician or immediate family member has a financial relationship Limited applicability to audiologists Civil, not criminal Denial of reimbursement, mandatory refunds, civil monetary penalties, exclusion from federal and state health care programs Potential $15,000 Civil Monetary Penalty/service Up to three times the amount claimed Some states have their own Stark Laws and may be broader than the federal law Office of the Inspector General A Roadmap Oversees the AKS Oversees fraud and abuse within Medicare/Medicaid More extensive auditing occurring Offers opinions on specific scenarios Published that you cannot charge a Medicare patient more than what you charge another patient for the same service States also have AKS laws for Medicaid ance/physicianeducation/roadmap_we b_version.pdf 82

False Claims False Claim (cont.) What is considered a False Claim?

Medicaid) Offenses: Submitting a claim for services not rendered Submitting a

provider number Falsifying a diagnosis Upcoding Unbundling a bundled code

medical records to certify patients for benefits Billing for phantom services

83 False Claims False Claim (cont.) What is considered a False Claim? Criminal offense to submit a false claim to the government (Medicare and Medicaid) Offenses: Submitting a claim for services not rendered Submitting a claim for services not medically necessary Not billing with the appropriate provider number Falsifying a diagnosis Upcoding Unbundling a bundled code (92557, 92540, and 92570) False Claims (cont.) SlidesCarnival icons are editable shapes. Can include: Overbilling Providing inferior products Falsifying claims and medical records to certify patients for benefits Billing for phantom services Duplicate billing Patterns of furnishing/billing for excessive or non-covered services Doug Lewis, JD, Ph.D., Au.D., MBA, Audiology Today JulAug 2012 SlidesCarnival icons are editable shapes. 83

agreement with the Office of Inspector General (OIG) for the U.S.

settlement resolves allegations that for nearly three years the practice improperly

performed by unqualified technicians http://oig.hhs.gov/fraud/enforcement/cmp/cmp-ae.

were arrested for $223 million in false claims A total of 600 providers for $2 billion

OIG Guidance SlidesCarnival icons are editable shapes. http://www.cms.

1994 stating may be considered indicators of potentially unlawful activity for failure

84 And then False Claims Act (cont.) Ear Nose and Throat Associates of Corpus Christi, LLC entered into a settlement agreement with the Office of Inspector General (OIG) for the U.S. Department of Health and Human Services, effective December 3, 2014 The $200,630 settlement resolves allegations that for nearly three years the practice improperly submitted claims to Medicare and Texas Medicaid for hearing assessment services performed by unqualified technicians In May, 2013, 89 physicians, nurses, and other health care providers in 8 cities were arrested for $223 million in false claims A total of 600 providers for $2 billion in fraud SLPs and the OIG SlidesCarnival icons are editable shapes. OIG Guidance SlidesCarnival icons are editable shapes. and-education/medicare- Learning-Network- MLN/MLNProducts/downloads/Fr aud_and_abuse.pdf Office of the Inspector General issued the Special Fraud Alert on December 19, 1994 stating may be considered indicators of potentially unlawful activity for failure to collect copayments or deductibles for a specific group of Medicare patients for reasons unrelated to indigency (e.g., a supplier waives coinsurance or deductible for all patients from a particular hospital, in order to get referrals). tml 84

severity/prosecution costs No specific intent to defraud is required Criminal penalties: Up to 5 years in prison and/or Up to

discovery of the overpayment Overpayment may be considered a false claim State False Claim laws may also apply Whistleblower

health insurance and health care delivery Improve access to long term care services and coverage Simplify the administration

gov/fdsys/pkg/plaw-104publ191/html/plaw-104publ191.htm HIPAA (cont.

85 False Claim (cont.) False Claims and the Affordable Care Act (2010) Civil penalties: $5,000-$11,000/claim Can be tripled depending on severity/prosecution costs No specific intent to defraud is required Criminal penalties: Up to 5 years in prison and/or Up to $10,000 in fines Report and return of overpayments made by Medicare and Medicaid Must be reported within 60 days of the discovery of the overpayment Overpayment may be considered a false claim State False Claim laws may also apply Whistleblower laws: 15-30% of total recovery Health Insurance Portability and Accountability Act of 1996 (HIPAA) SlidesCarnival icons are editable shapes. Allows for portability and continuity of health care for those who changed or lost their jobs Combat fraud, abuse and waste in health insurance and health care delivery Improve access to long term care services and coverage Simplify the administration of health insurance Promote the use of medical savings accounts HIPAA (cont.) Must have policies and procedures that include: Notice of Privacy Practices (NPP) How Personal Health Information (PHI) is treated Encryption to prevent lost or stolen information s Patient s current, past and future health care information How a violation of PHI will be dealt with if lost, stolen or disclosed Perform annual documented HIPAA staff trainings and risk analyses Appoint an privacy officer 85

86 HIPAA (cont.) Business Associate/Agreement Transaction and Code Sets (10/16/03) Privacy (4/14/03) Protecting personal health information Notice of Privacy Practices- 9/23/13 Marketing/Remuneration and fund-raising changes How patients want their PHI to be handled Update patient info/signature annually Business Agreements (BA) Revise-BAs are now subject to HIPAA penalties (9/23/13) What Is a Business Associate? A business associate is a person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity. A member of the covered entity s workforce is not a business associate. A covered health care provider, health plan, or health care clearinghouse can be a business associate of another covered entity. The Privacy Rule lists some of the functions or activities, as well as the particular services, that make a person or entity a business associate, if the activity or service involves the use or disclosure of protected health information. The types of functions or activities that may make a person or entity a business associate include payment or health care operations activities, as well as other functions or activities regulated by the Administrative Simplification Rules. Business associate functions and activities include: claims processing or administration; data analysis, processing or administration; utilization review; quality assurance; billing; benefit management; practice management; and repricing. Business associate services are: legal; actuarial; accounting; consulting; data aggregation; management; administrative; accreditation; and financial. See the definition of business associate at 45 CFR HIPAA Privacy HIPAA (cont.) To protect Personal Health Information (PHI): Patient s names Patient demographic information and contact information Social security number Insurance information and plan numbers Patient s state driver s license and VINs Photo on driver s license NOAH must be password protected Contains PHI, audiometric data and hearing aid serial numbers Security (4/21/05) To protect data integrity, confidentiality Physical safeguards, technical data and technical security services Passwords-for all systems and stand alone software Biometrics Electronic signatures Work PC NOAH Thumb drives, , CDs Disaster recovery Theft, fire, intrusion, other environmental hazards Data breaches HIPAA (cont.) Minimum necessary Each facility/practice needs to have a HIPAA compliant program in place Appoint a privacy officer Policy must be available in waiting area and a copy offered to patients Patient signs the Notice of Privacy Practices (NPP) Encryption-computers, fax, copiers Health Care Providers -Audiologists Every health care provider, regardless of size, who electronically transmits health information in connection with certain transactions, is a covered entity All providers of services (e.g., institutional providers such as hospitals) and providers of medical or health services (e.g., noninstitutional providers such as physicians, dentists and other practitioners) as defined by Medicare, and any other person or organization that furnishes, bills, or is paid for health care Transactions include claims, benefit eligibility inquiries, referral authorization requests, or other transactions for which HHS has established standards under the HIPAA Transactions Rule The Privacy Rule covers a health care provider whether it electronically transmits these transactions directly or uses a billing service or other third party to do so on its behalf Source: 86

87 Security Rule Risk Assessment for Security established a national set of security standards for protecting certain health information that is held or transferred in electronic form. A major goal of the Security Rule is to protect the privacy of individuals health information while allowing covered entities to adopt new technologies to improve the quality and efficiency of patient care Safeguards must be put in place to secure individuals electronic protected health information ( ephi ) Source: Anytime a breach of PHI occurs, a risk assessment must be completed Should include the following possibilities for risk as a result of these factors and the measures in place to address them: Natural: Floods, earthquakes, tornadoes, landslides, avalanches, electrical storms, and other such events. Human: Events that are either enabled by or caused by human beings, such as unintentional acts (inadvertent data entry) or deliberate actions (network based attacks, malicious software upload, unauthorized access to confidential information). Environmental: Long-term power failure, pollution, chemicals, and liquid leakage. HIPAA (cont.) HIPAA (cont.) Minimum necessary Each facility/practice needs to have a HIPAA compliant program in place Need to have a privacy policy for your office Must be accessible and offered to all patients They need to sign a Notice of Privacy Policy (NPP) attesting to how they want their PHI handled Includes mailings, voice mail messages Policy must be available in waiting area and a copy offered to patients Annual training for staff Office of the Civil Rights (OCR) has responsibility for enforcement Audits Practices are being currently being audited If billing electronically, you are a covered entity (CE) As a CE, you need to have business agreements (BA) with those companies with whom you exchange PHI Hearing aid vendors Earmold vendors Others Need plans in place to protect personal health information HIPAA Requirements: HIPAA (cont.) Written procedures with recovery plan Passwords Physical safeguards Locked cabinets if patient health information is contained therein Backed up information stored offsite Secure a HIPAA IT specialist Plan if breaches occur Need to determine low level of probability Civil and criminal penalties Civil: $100-$25,000 per calendar year Correction within 30 days may lessen the penalty Monetary penalties only Criminal: Up to $50,000 and imprisonment for up to one year 87

88 Health Information Technology for Economic and Clinical Health Act (HITECH) (ARRA 2009) 11/30/09; 1/11/11; 1/1/12 Notification if there is a breach (2/17/10) Acquisition, access, use or disclosure of PHI not permitted by Privacy rules First class mail notification within 60 days of discovery of breach Dependent on how many are affected Must report to those who were affected and to the Department of Health and Human Services (HHS) within 60 days of discovery if over 500 patients are identified If over 500 patients affected, must contact local media Business Associates need to implement their own HIPAA compliant programs HIPAA/HITECH Changes Effective September 23, 2013: Update your Notice of Privacy Practices (NPPs) New requirements for marketing and fundraising Required to redistribute to patient and displayed prominently Update security policy with breach notification specified Business Associates (BAs) having subcontractors must also have BAs if they handle Personal Health Information (PHI) Must notify CEs if there is a breech Check with manufacturers, clearinghouses, other vendors who handle PHI 524 HIPAA/HITECH Changes (cont.) HIPAA HITECH (cont.) Patients can request that a claim for their services not be submitted to their payer if they pay privately Patients may request their electronic record and it must be supplied to them in this manner, if possible Marketing New rules apply when a communication about a product or service that encourages recipients of the communication to purchase or use the product or service. Applies to your patient s data Manufacturer implications HIPAA HITECH (cont.) HIPAA/HITECH (cont.) Implications include: Manufacturer sponsored open houses Manufacturer sponsored marketing Business development funds for marketed products Discounts or promotions Fines will rise to up to $1.5 million maximum per calendar year and up to 10 years imprisonment Patients rights to receive electronic copies of their health records Encryption If can t deliver records electronically, must be able to provide in another manner Patients may restrict disclosures to health plan if they pay privately, in full Data breaches with anything other than a low probability of compromise must be reported to the affected patients and the federal government Risk assessments should be conducted, must be if a breach Process must be explained to patients, posted on practice websites

89 Breach Notification Breach Notification (cont.) Definition of Breach A breach is, generally, an impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of the protected health information. An impermissible use or disclosure of protected health information is presumed to be a breach unless the covered entity or business associate, as applicable, demonstrates that there is a low probability that the protected health information has been compromised based on a risk assessment of at least the following factors: The nature and extent of the protected health information involved, including the types of identifiers and the likelihood of re-identification; The unauthorized person who used the protected health information or to whom the disclosure was made; Whether the protected health information was actually acquired or viewed; and The extent to which the risk to the protected health information has been mitigated. Covered entities that experience a breach affecting more than 500 residents of a State or jurisdiction are, in addition to notifying the affected individuals, required to provide notice to prominent media outlets serving the State or jurisdiction. These individual notifications must be provided without unreasonable delay and in no case later than 60 days following the discovery of a breach and must include, to the extent possible, a brief description of the breach, a description of the types of information that were involved in the breach, the steps affected individuals should take to protect themselves from potential harm, a brief description of what the covered entity is doing to investigate the breach, mitigate the harm, and prevent further breaches, as well as contact information for the covered entity (or business associate, as applicable). Breach Notification (cont.) If a breach affects 500 or more individuals, covered entities must notify the Secretary without unreasonable delay and in no case later than 60 days following a breach. Examples of Data Breaches: Recent HIPAA Breaches: Cignet Health in Maryland--$4.3 million civil monetary penalty ($1.5 million CMP/willful violation)-patient requests for records denied Massachusetts General Hospital--$1 million Several hundred patient records left on the subway Some were HIV patients Carelessness results in most breaches; many have been theft New York Presbyterian and Columbia University-PHI publicly available, lack of policies/protections: $4.8 million Concentra-theft of unencrypted laptop: $1.7 million (QCA Health Plan: $250,000) Skagit County, WA-PHI on a server, publicly available $215,000 Ober-Kaler presentation 89

Examples (cont.) HIPAA Violations (cont.) HealthNet in CA-$1.

no SS #s Paper containing password was missing Data encrypted First jailed HIPAA violator (4 months)-cardiothoracic surgeon/researcher Viewed patient records, including his

party rental business and a car HIPAA (cont.

regulations: Must provide information and be in compliance regarding sterilization of equipment and other instrumentation Label alcohol, disinfectants, etc.

(Occupational Safety and Health Act) Occupational Safety and Health Act In An Audiology Practice Employee Training Employers must ensure that their employees who have the

The program's structure must include training at the time of initial assignment and then at least annually thereafter.

90 Examples (cont.) HIPAA Violations (cont.) HealthNet in CA-$1.9 million subscribers on missing hard drives HealthNet in CT-data security breach UCLA-former employee s computer stolen during a home burglary Contained PHI on 16,288 pts, no SS #s Paper containing password was missing Data encrypted First jailed HIPAA violator (4 months)-cardiothoracic surgeon/researcher Viewed patient records, including his supervisor s, co-workers, celebrities; did not have authorization for review Nearly 300,000 Kaiser Permanente hospital records were stored in a warehouse shared with a party rental business and a car HIPAA (cont.) Occupational Safety and Health Act (OSHA) August 2015, Excellus Blue Cross/Blue Shield had a cyber attack that affected 10 million individuals On both sides of the regulations: Must provide information and be in compliance regarding sterilization of equipment and other instrumentation Label alcohol, disinfectants, etc. Testing for manufacturers Hearing loss incurred due to noise, solvents, gases or a combination Subject matter expert Forensic audiology Infection Control Resources (Occupational Safety and Health Act) Occupational Safety and Health Act In An Audiology Practice Employee Training Employers must ensure that their employees who have the risk of occupational exposure participate in the training program that is provided during the employee's normal working hours. The program's structure must include training at the time of initial assignment and then at least annually thereafter. The standard specifies that the annual training must be provided within one year of the previous training date Some states require it as part of licensure (NY, FL) 90

Occupational Safety and Health Act In A Speech-Language Pathology Practice Federal Drug Administration http://www.asha.org/slp/infectioncontrol/https://www.osha.

htm Some states require it as part of licensure (NY, FL) SLPs and the FDA Classification of Speech Training Aids SlidesCarnival icons are editable shapes. http://www.fda.

gov/medicaldevices/productsandmedicalprocedures/homeh ealthandconsumer/consumerproducts/hearingaids/ucm181484.htm FDA Red Flags Get a check up.

The medical exam will rule out any medical reason for your hearing loss which would require medical or surgical treatment.

Your doctor can also give you a referral to an audiologist or a hearing aid dispenser if your health plan requires a doctor s referral for services.

However, FDA believes that it is in your best health interest to have the medical exam by a licensed physician before buying hearing aids. Consider going to an audiologist.

Buy your hearing aid from a licensed hearing healthcare professional. This will typically be an audiologist, a hearing aid dispenser, or an ear, nose, and throat physician.

91 Occupational Safety and Health Act In A Speech-Language Pathology Practice Federal Drug Administration dte/outreach/intro_osha/intro_to_osha_guide.html Some states require it as part of licensure (NY, FL) SLPs and the FDA Classification of Speech Training Aids SlidesCarnival icons are editable shapes. mitteesmeetingmaterials/medicaldevices/medicaldevice sadvisorycommittee/earnoseandthroatdevicespanel/u CM pdf From ealthandconsumer/consumerproducts/hearingaids/ucm htm FDA Red Flags Get a check up. Go to a doctor, preferably an ear, nose, and throat physician (also known as an otolaryngologist) to get a medical exam. The medical exam will rule out any medical reason for your hearing loss which would require medical or surgical treatment. You will receive documentation of your medical exam and a statement that says you are a candidate for hearing aids. Your doctor can also give you a referral to an audiologist or a hearing aid dispenser if your health plan requires a doctor s referral for services. Note: You have the option to sign a waiver saying you do not want a medical exam to rule out any medical reason for your hearing loss. However, FDA believes that it is in your best health interest to have the medical exam by a licensed physician before buying hearing aids. Consider going to an audiologist. An audiologist will perform an audiological exam to determine the type and amount of your hearing loss, and will counsel you as to your nonmedical options to improve your hearing loss. Buy your hearing aid from a licensed hearing healthcare professional. This will typically be an audiologist, a hearing aid dispenser, or an ear, nose, and throat physician. Provide your documentation that you received from your doctor that states you are a hearing aid candidate. Ask your hearing healthcare professional to help you determine what features you will need. Visible congenital or traumatic deformity of the ear. History of active drainage from the ear in the previous 90 days. History of sudden or rapidly progressive hearing loss within the previous 90 days. Acute or chronic dizziness. Unilateral hearing loss of sudden or recent onset within the previous 90 days. Audiometric air-bone gap equal to or greater than 15 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz. Visible evidence of significant cerumen accumulation or a foreign body in the ear canal. Pain or discomfort in the ear. 91

92 American Disabilities Act (ADA) Reimbursement Resources Promulgated in 1990 An Act to establish a clear and comprehensive prohibition of discrimination on the basis of disability. Audiologists may be on both sides of this: You are required to make your office as accessible as possible Physical accessibility as well as providing interpreters for the hearing impaired Can t charge the patient for this service You may be requested to offer subject matter expert assistance if someone challenges their lack of accessibility regarding hearing loss and amplification accommodations edicare/pages/medicare_faq.aspx edicare/documents/201105_cms_1500_form_at_a _Glance.pdf edicare/documents/enrollmentoptions4medicare.pd f Scenario #1: Scenario #1 Response: My patient and I both want to know what the insurance payment will be for his binaural hearing aids. Since that insurance company won t give us the amount, I submit the claim to see what his out of pocket expenses will be so that we all know what he will be responsible for and will then dispense his hearing aids. Criminal offense to submit a false claim to the government (Medicare and Medicaid) Offenses: Submitting a claim for services not rendered Submitting a claim for services not medically necessary Not billing with the appropriate provider number Falsifying a diagnosis Up coding Unbundling a bundled code (92557, 92540, and 92570) Scenario #2 Scenario #2 Response My insurance company s fee schedule offers $6000 for binaural hearing aids. A month after the premium devices were dispensed, they sent me a letter requesting $3000 back due to an error in payment. The patient must return the devices and we will have to give her lesser technology. Submit an appeal to the insurance company Secure guidance from your state s insurance department Secure an opinion from your state licensure board Secure an opinion from your professional organizations ethical practice committees 92

93 Scenario #2 Response (cont.) Scenario #3 You are providing what you and the patient agreed upon and did so in good faith with the payer Waivers may be beneficial in this instance so the patient understands there may be a reconfiguration of their benefit for which they should alert their Human Resource department I perform pure tone air conduction, speech reception thresholds and word recognition I bill CPT code Thoughts? Scenario #3 Response Scenario #4 CPT code requires pure tone aid AND bone conduction, speech reception thresholds and word recognition If you don t complete all of the components of what is required, use the -52 modifier for reduced services It may not be recognized by the payer, but it must be appended I perform tympanometry and ipsilateral acoustic reflex thresholds bilaterally. I file the claim for Thoughts? Scenario #4 Response Scenario #5 CPT code includes ipsilateral and contralateral frequencies for a total of 14 reflexes 4 Contra right and left ears (8) 500, 1000, 2000 and 4000 Hz 3 Ipsilateral right and left ears (6) 500, 1000 and 2000 Hz I perform tympanometry but can t get a seal Can I bill for this procedure? 93

Scenario #5 Response Scenario #6 If you attempt a procedure and have that documented, suggest billing it with: -52 Per the AMA s Coding with Modifiers 5 th edition: Modifier

I perform a Dix Hallpike maneuver How do I bill for this? Scenario #6 Response Your Turn!

) Outcome measures Best practices Online hearing aids Providing services to patients who purchased online?

94 Scenario #5 Response Scenario #6 If you attempt a procedure and have that documented, suggest billing it with: -52 Per the AMA s Coding with Modifiers 5 th edition: Modifier 52 is appended when a service or procedure is partially reduced or eliminated at the physician s discretion ie., started but discontinued. I perform a Dix Hallpike maneuver How do I bill for this? Scenario #6 Response Your Turn! It is included as a position--cpt code Changing Landscape Changing Landscape (cont.) Outcome measures Best practices Online hearing aids Providing services to patients who purchased online? Office policy for hearing aids not purchased in your office Specify services/fees for devices purchased from an audiologist or hearing aid dispenser Specify services/fees for online purchased devices You may be in violation of existing contracts if you refuse to service these patients with these devices Itemize Charge for the services you are providing Hearing Loss Association of America promotes itemization for transparency in costs and services 94

95 Changing Landscape (cont.) Audiology Relevancy The marriage of one hearing aid company and one third party payer is likely just the beginning There s an app for that iphone applications for testing and for the dispensing of hearing aids and other wearables Consider providing other niche services: Vestibular services Tinnitus services Central auditory processing diagnostics and treatment Assistive listening devices Looping services Support staff Audiology aides/assistance, if recognized by state licensure Areas of interest and potential in offering hearing and balance services in this dynamic environment It s not about the widget For your consideration. Changing Landscape Outcome measures similar à la PQRS Methodology for Medicare reimbursement in 4-6 years?? Best practices will prevail in payment paradigms Online hearing aids and PSAPs Providing services to patients who purchased online? Office policy for hearing aids not purchased in your office Specify services/fees for devices purchased from an audiologist or hearing aid dispenser Specify services/fees for online purchased devices Providing services to patients who want the cheat(p)er level of technology Office policy Changing Landscape (cont.) Changing Landscape (cont.) You may be in violation of existing contracts if you refuse to provide services to these patients with these devices Itemize Charge for the services you are providing Hearing Loss Association of America promotes itemization for transparency in costs and services The marriage of one hearing aid company and one third party payer hihealth Innovations and United Health Care Others Big box retail Costco Sam s Walmart Online Hearing Planet Hearing aids 95

96 Changing Landscape (cont.) Federal Drug Administration (FDA) There s an app for that iphone applications for testing and for the dispensing of hearing aids and other wearables Starkey s Halo, Muse, Soundlens Soundhawk Eargo Audicus Others Class I Hearing aids Class II Tinnitus devices/auditory trainers Class III Cochlear implants SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. Starkey 96

Eargo SlidesCarnival icons are editable shapes.

Other Disruptions: Audiology Relevancy Codes for

providing other niche services: Vestibular

processing diagnostics and treatment Assistive

Support staff Audiology aides/assistance, if

Assessment of tinnitus (includes pitch, loudness

97 Eargo SlidesCarnival icons are editable shapes. SlidesCarnival icons are editable shapes. Other Disruptions: Audiology Relevancy Codes for Tinnitus Evaluation and Treatment Consider providing other niche services: Vestibular services Tinnitus services Central auditory processing diagnostics and treatment Assistive listening devices Wearables Looping services Support staff Audiology aides/assistance, if recognized by state licensure CPT code: Assessment of tinnitus (includes pitch, loudness matching, and masking) Other tests performed ICD-10 code: H93.1 H93.11 Tinnitus, right ear H93.12 Tinnitus, left ear H93.13 Tinnitus, bilateral H93.19 Tinnitus, unspecified ear 97

98 Codes for Central Auditory Processing Disorders CAPD (cont.) CPT codes: Evaluation of central auditory function, with report; initial 60 minutes Evaluation of central auditory function, with report; each additional 15 minutes ICD-10 codes: H93.2 Other abnormal auditory perceptions H93.25 Central auditory processing disorder H93.29 Other abnormal auditory perceptions H Other abnormal auditory perceptions, right ear H Other abnormal auditory perceptions, left ear H Other abnormal auditory perceptions, bilateral H Other abnormal auditory perceptions, unspecified ear Codes for Vestibular Evaluation Codes for Vestibular Evaluation (cont.) Basic vestibular evaluation Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording Positional nystagmus test, minimum of 4 positions, with recording Caloric vestibular test with recording, bilateral; bithermal (i.e., one warm and one cool irrigation in each ear for a total of four irrigations) OR Monothermal, (i.e., one irrigation in each ear for a total of two irrigations) Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording Oscillating tracking test, with recording Sinusoidal vertical axis rotational testing Use of vertical electrodes (list separately in addition to code for primary procedure) Computerized dynamic posturography Codes for Vestibular Treatment Codes for Cochlear Implant Services CPT codes: Canalith Repositioning Procedure Check with payers; Medicare and others will not recognize audiologists for this procedure ICD-10 codes: R42 Dizziness and giddiness H81.1 BPPV H81.0-H83.2X Other dizzy related codes CPT codes: Diagnostic analysis of cochlear implant, patient under 7 years of age; with programming Diagnostic analysis of cochlear implant, patient under 7 years of age; subsequent reprogramming Diagnostic analysis of cochlear implant, age 7 years or older with programming Diagnostic analysis of cochlear implant, age 7 years or older with reprogramming 92626/7 Evaluation of auditory rehabilitation status, first hour/each additional 15 minutes 98

99 Codes for Cochlear Implant Services (cont.) ICD-10 codes: H90.3 SNHL, bilateral H90.41 SNHL, right ear H90.42 SNHL, left ear H90.5 Unspecified HL (several listed as NOS, not otherwise specified) IONM and Nerve Conduction Study CPT Codes (1/1/13) CPT code 95940: Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes Must bill with CPT code 95941: Continuous intraoperative neurophysiology monitoring from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour Must bill with Can t bill outside of OR to Medicare IONM and Nerve Conduction Study CPT Codes (cont.) IONM and Nerve Conduction Study CPT Codes (cont.) G0453 Continuous IONM from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes List with Billed in units of 15 minutes CPT codes CPT code Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report Code chosen is dependent on the number of completed studies: CPT code 95905: Report only once per limb studied CPT code 95907: Nerve conduction studies 1-2 studies CPT code 95908: 3-4 studies CPT code 95909: 5-6 studies CPT code 95910: 7-8 studies CPT code 95911: 9-10 studies CPT code 95912: studies CPT code 92913: 13 or more studies IONM ICD codes Codes for Auditory Rehabilitation ICD-10 Code for the reason for the test, type of hearing loss or other audiologic/pre-diagnosed findings CPT codes: Assessment of auditory rehabilitation status; first hour each additional 15 minutes Auditory rehabilitation; prelingual hearing loss Auditory rehabilitation; postlingual hearing loss 99

100 Codes for Auditory Rehabilitation (cont.) Common Audiology Coding Errors ICD-10 codes: H Other abnormal auditory perceptions, unspecified ear H90.3 SNHL, bilateral H90.41SNHL, uni, right ear, with unrestricted hearing contralateral side H90.42 SNHL, uni, left ear, with unrestricted hearing contralateral side H90.3 SNHL, bilateral H90.8, H90.71, H90.72, H90.6 Mixed hearing loss family H90.5 Unspecified SNHL R Abnormal auditory function study I perform pure tone air, speech reception thresholds and word recognition testing bilaterally The patient has normal hearing acuity, so I don t perform bone conduction I bill Modifiers (cont.) Common Audiology Coding Errors -52 Reduced services Procedure is partially reduced or eliminated Discontinued at provider s discretion after the procedure commenced Can be used to indicate monaural vs. binaural testing Can be appended to indicate that not all requirements of the code were completed Not recognized by all carriers Example: I don t get reimbursed enough for for all that I do (case history, otoscopy, testing, counseling) but I do it anyway The patient wants to proceed with hearing aids and returns for a hearing aid evaluation I perform CPT code 92626, Evaluation of Auditory Rehabilitation Status to discuss hearing aid options I bill to Medicare Guidance on CPT code AAA, ADA, ASHA guidance Evaluation of auditory rehabilitation status, first hour 92627, Evaluation of auditory rehabilitation status; each additional 15 minutes Use to report the function of a patient pre and/or post them receiving unilateral or bilateral hearing devices including: Hearing aid(s) Auditory osseo-integrated implant(s) Middle ear implant(s) Cochlear implant(s) Auditory brainstem implant 100

101 Guidance (cont.) Finally AMA s CPT Assistant, July 2014 states: the evaluation will determine the need for auditory rehabilitation following the fitting and verification of hearing devices and may also be used to monitor the progress of therapeutic intervention. To determine the need for rehabilitation Check with patient s third party payer In the example, should use one of the hearing aid evaluation codes: (monaural) or (binaural) or V5010 Choice will likely be payer dependent Check your fee schedules Do not bill this scenario to Medicare Hearing aids are not a covered service Should use for: Cochlear implant(s) Osseo-integrated device(s) Auditory brainstem implant Include what and why you performed what you did in your documentation Medical Necessity Scenario Medical Necessity Definition Our office policy is for the initial visit, the patient must have comprehensive audiometry (92557), tympanometry and reflexes (92550) and otoacoustic emissions (92587) They have a symmetric 60 db HL SNHL AU with goodexcellent WRS, tympanograms within normal limits and reflexes present at all frequencies tested Does performing tympanometry, reflexes and OAEs meet medical necessity? Title XVIII of the Social Security Act, section 1862 (a)(1)(a): Notwithstanding any other provisions of this tile, no payment may be made under Part A or Part B for any 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 One more Code Descriptor I perform tympanometry and acoustic reflex thresholds ipsilaterally I bill Is this correct? Procedure is to be ipsilateral and contralateral, bilaterally for more than 2 reflexes 101

102 No SlidesCarnival icons are editable shapes. Should use the -52 modifier for reduced services since you are not performing all the requirements listed for the code Some payers may not recognize it, but must append it Questions? Debbie Abel, AuD Manager, Coding and Contract Services

MODEL SUPERBILL for AUDIOLOGY

MODEL SUPERBILL for AUDIOLOGY The following is a model of a superbill which could be used by an audiology practice when billing private health plans. This sample is not meant to dictate which services