Billing, Coding, & Calculating Fees: Finding Success

Billing, Coding, & Calculating

Fees: Finding Success

Janet McCarty

Today’

s Agenda

 BILLING: Learn how to bill for your services.

 CODING: Learn the codes that describe the services you provide. Use these

codes to communicate with health plans.

 CALCULATING FEES: Learn how to determine fees for your services.

BILLING: Superbills

 Use a Superbill (Billing, Coding, Charges)

 List ICD-9 and CPT codes used most often in

your practice

 Provide patient information

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

ICD-9 & CPT Codes

 ICD-9 (International Classification of

Diseases) codes describe the diagnosis  CPT (Current Procedural Terminology)

Filing A Claim

 Clinician decides whether patient or provider files claims

 If the patient files, you will need to

provide a bill with CPT & ICD-9 codes, charges, and supporting documentation  If you have a signed agreement with

Remember…

Health plan coverage is an arrangement between the patient and health plan.

Clinicians provide necessary

documentation, but always make it clear to patients that they are ultimately

Review Patient’

s Policy

 Are audiology or speech-language services covered?

 Claim decisions are based on contract wording. Is coverage clear or vague?

Filing A Claim

 Be sure to obtain patient permission to supply the health plan with relevant

Contact Provider Relations

 What is your provider status?

 Is your setting recognized (private practice, university clinic)?

 Do you need a provider #?

 What documentation is necessary?  Pre-authorization needed?

National Provider Identifiers

(NPIs)

 Effective May 2007, providers and

organizations defined as covered entities

under HIPAA will be required to have an NPI

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

obtaining an NPI: https://nppes.cms.hhs.gov

 ASHA Web site for NPI information:

Billing Policies

Q. Can I waive co-payments?

A. Usually not. Payers view the routine

waiver of patient payments as a breach of contract. Medicare/Medicaid co-pay waivers are not allowed and are viewed as false claims.

Waiving Co-pays

 If provider’s fee is $100, but the Medicare 20% co-pay is waived routinely, the federal gov’t. says

Medicare should be billed $64 (80% of $80 vs. 80% of $100), and submitting a $100 claim is a false claim.

Can I offer a sliding scale?

 Yes. Be sure to have a defined policy and procedure for consistent

administration.

 Have a written policy that establishes guidelines for determining a patient’s indigency.

 Contact local welfare clinics to learn the community standard.

 Medicare/Medicaid allows for limited documented indigency.

Examples of Health Care

Provider Fraud

 Billing for services not performed

 Falsifying a patient’s diagnosis to justify tests

 Upcoding, or billing for a more costly service than the one performed

 Unbundling, or billing for each stage of a procedure as if it were separate

Office Billing Policies

Providers should monitor their practices to ensure compliance with all applicable federal and state laws when determining billing

policies.

For more information on Billing Policies, go to The ASHA Leader Online at

http://www.asha.org/about/publications/leader-online/archives/2006/060905/060905a.htm

CODING

You must be able to support your coding decisions with patient history, physician referral information, evaluation results, and other documentation that supports your professional judgment as to the

cause of the patient’s condition and required treatment.

Coding A Diagnosis

Originally, coding allowed retrieval of

information by diagnoses for purposes of medical research and education. “Coding today is used to describe the medical

necessity of a procedure.”

ICD-9 Coding

 Determine a diagnosis based on test results and assign a diagnostic code  Assign the best, or most appropriate

diagnostic code

ICD-9 Coding

 Determine the highest level of

specificity, which means using the 5th digit. For example:

 Don’t use 784.6 (symbolic dysfunction).

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

Coding To 5

Digit

Keep in mind that 784.60, 784.61, 784.69 are subclassifications of 784.6, so when you use those codes, you are not

Coding To 5

Digit

 Assign 3 digits when there are no 4 digit codes.

 Assign 4 digit codes if there is no 5th digit subclassification.

 Assign the 5th digit subclassification code for those categories where it exists.

Coding Normal Results

 Many payers will not reimburse for evaluation

results reported “within normal limits.”

 When coding an uncertain diagnosis

(“suspected,”“rule out”), code the condition as if it existed.

 When testing produces a normal result,

report the sign & symptom or chief complaint as the primary diagnosis.

Signs/Symptoms Associated With

Aphasia; Language Disorders

 Difficulty speaking

 784.5 (speech disturbance)

 Difficulty understanding spoken language

 784.3 (aphasia)

 Cognitive deficits

 784.60 (symbolic dysfunctions, unspecified)

Signs/Symtoms Associated

With Audiology

 Difficulty hearing in noise

 389.9 (unspecified hearing loss)

 Acoustic trauma

 388.11 (acoustic trauma, explosive, to ear)

 Delayed speech/language

 315.39 (dev. articulation disorder) or 783.42(delayed milestones; late

Coding Procedures

 Use CPT codes to describe the service or treatment

 Choose the CPT procedure code that best describes the services

CPT Coding: Time

Components

 There are no time components associated with many SLP/AUD procedure codes

 Asking for time-based codes can be risky

 Time is already factored into relative value process

CPT Coding: Using Modifiers

 -22 Unusual services: the service provided is greater than that usually required

 -52 Reduced services: procedure is partially reduced

CPT Coding

 Understand the CPT Process  Step 1 & Step 2

The CPT Process

–

Step 1

 Owned by the American Medical Association (AMA)

 ASHA’s Health Care Economics Committee proposes new codes

 Multiple-step process for approving new codes

The CPT Process

–

Step 2

1. The AMA Relative Value Committee

“values”the procedure, or new code, and makes a recommendation to CMS (Centers for Medicare/Medicaid)

2. CMS revalues the procedure taking into account: work, time involved, professional liability, equipment &

CALCULATING FEES

 Health care providers have some

flexibility when setting private fees.  Clinicians can choose a pricing

philosophy, and then gather available charge information to establish a fee schedule and negotiate health care contracts.

Choosing A Pricing Philosophy

1. Market-driven approach: Known as UCR

(usual, customary, reasonable) ties medical pricing to industry trends in local

communities; assumes patients are price-sensitive.

2. Relative value approach: Fees are tied to

“worth”of a procedure and considers skill, time, risk. Medicare Physician Fee Schedule uses the relative value method.

Available Fee Data

 Compare your fees with the Medicare

Physician Fee Schedule.

 Use the fee data (from Milliman) found in

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

 The Milliman fee data cannot be directly

shared beyond ASHA members, but can be used as a reference for negotiating rates.

Calculating Fees: WARNING

Setting prices in collusion with colleagues is illegal. Avoid price-fixing, such as

Understanding Fee Data

 50th percentile: 50% of charges are

below this rate; 50% of charges are at or above this rate.

 75th percentile: 75% of charges are

below this rate; 25% of charges are at or above this rate. (Ingenix)

 Milliman data: average charges for services

Calculating the Medicare

Reimbursement Rate

CPT 92585 (Auditory Evoked Potentials; comprehensive)

Physician Work RVUs 0.50 Practice Expense RVUs 2.06

Malpractice RVUs 0.17

TOTAL RVUs 2.73

Fee Data

CPT 92506 (Speech & Language Eval.) 50th _{percentile: $144.36}

75th _{percentile: $210.47} Medicare rate: $132.26 Milliman data: $152.71

Fee Data

CPT 92507 (Speech-Lang. Treatment) 50th _{percentile: $68.82}

75th _{percentile: $100.33} Medicare rate: $62.53 Milliman data: $117.66

Fee Data

CPT 92557 (Comprehensive Audiometry Evaluation)

50th _{percentile: $96.14} 75th _{percentile: $118.22} Medicare rate: $49.65 Milliman data: $86.04

Fee Data

CPT 92567 (Tympanometry) 50th _{percentile: $37.70} 75th _{percentile: $46.36} Medicare rate: $21.98 Milliman data: $39.96

Establishing Fees

Establishing fees takes care. Fees that are too high will lead to disputes with

patients and payers. Fees that are too low will result in inadequate

Negotiating Better

Reimbursement Rates

Negotiating Better

Reimbursement Rates

Step 1

Determine the most common CPT codes

-Codes that account for 75% of your total practice charges

-Record the # of times you provided the service over 12-month period (CPT 92557: frequency 500)

Negotiating Better Rates

Step 2

Determine your top payers

-Focus on 3-4 payers = bulk of your reimbursement

-Medicare/Medicaid use established fee schedules and do not negotiate

Negotiating Better Rates

Step 3

Determine your reimbursement for each code

-Note how much each payer allows for each code on your list

-Calculate each payers’reimbursement as a % of Medicare’s fee schedule

Calculate Payer Rate As A %

of Medicare Rate

113% $25.00 $21.98 92567-Tymp. Payer Payment as a % of Medicare Health Plan Rate Medicare Allowed Amt. CPT

Negotiating Better Rates

Step 4

Review your fees for each code

-Calculate your fees as a percentage of Medicare’s rates

Calculate Your Fees As A % of

Medicare’

s Rate

159% $35.00

$21.98 92567

Your fee as a % of Medicare Your Current Fee Medicare Allowed Amt. CPT

Negotiating Better Rates

Organize and analyze the data

-Compare rates between plans

-If payer reimburses in full, may mean your fees are too low. Plan may be willing to pay more.

-Consider raising fees or standardize all your fees at some % of Medicare, say 125%

Negotiating Better Rates

Organize & analyze the data

-Is one plan’s rates lower, or is one code paid at a much lower % of

Medicare than others?

-Establish target reimbursement rates for your negotiations, say 120% of

Develop An Action Plan

 Negotiate individual fees: Your first contact

might be Provider Relations rep, then the Contracting Manager

 Drop the plan: Rates too low, no longer

accept patients. Patients may find another provider, or complain to their employer.

 Close to new patients if you don’t want to

Coding Examples

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

Coding Example

 Case: Patient seen for voice prosthesis evaluation and fitting.

 ICD-9 diagnostic code: from physician  784.41 (aphonia)

 primary vs. secondary diagnosis

 CPT procedure code: 92597 (eval for use/fitting of voice prosthesis)

Coding Example

 Case: Patient needs modification of trach-esophageal prosthesis during follow-up visit

 ICD-9 code: from physician  784.41 - aphonia

 CPT code: 92507 (speech-language treatment).

Coding Example

 Case: Audiological eval reveals

sensorineural hearing loss bilaterally. Middle ear function WNL.

 ICD-9 code: 389.18 (sensorineural hearing loss of combined types, bilateral)

 CPT code: 92557, 92567, 92568, 92569 (comprehensive aud., tymp., acoustic reflex testing, decay)

Coding Example

 Case: A 35 y/o male has impaired

language & cognitive skills after head injury.

 ICD-9 code:784.69 (symbolic dysfunction, coded to 5th _digit)

Coding Example



Case: 35 y/o male is

cognitive/language impaired due to

head injury

 ICD-9 code: 784.69

 CPT code: 92507 (speech-lang. treatment)

OR

 97532 (development of cognitive skills to improve attention, memory…)

Coding Example

 Case: 4-month old boy is seen for

auditory brainstem response (ABR) to rule out hearing impairment.

 ICD-9 code: 389.18 (sensorineural hearing loss of combined types; bilateral) or 389.9 (unspecified hearing loss)

 CPT code: 92585 (auditory evoked

potentials); 92588 (evoked otoacoustic

Coding Example

 Case: 5 y/o with unintelligible speech is diagnosed with language impairment

and verbal apraxia.

 ICD-9 code: 784.69 (apraxia) Verbal apraxia tests confirm this diagnosis.  CPT code: 92506 (speech-lang. eval.)

Coding Example

 Case: Auditory rehabilitation for a 66 y/o female.

 ICD-9 code: 389s (Hearing Loss)

 CPT code: 92633 (auditory rehabilitation post-lingual hearing loss)

Coding Example

Case: Patient has normal hearing. Q. How do you code the diagnosis? A. Code the referring diagnosis.

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

Coding Example

 Case: Patient seen for bedside swallowing assessment.

 ICD-9 code: 787.2 (dysphagia)  CPT code: 92610 (evaluation of

Coding Example

Case: SLP performs a speech-language

evaluation and treatment on the same date of service. What would you code?

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

Coding Example

Case: SLP participates in fiberoptic

endoscopy but does not actually insert the endoscope. What would you code? Answer: 92610 (bedside swallow)

because SLP did not actually insert the endoscope.

A Great Resource

 ASHA’s Billing and Reimbursement Web Site: www.asha.org/members/issues/reimbursement/

 Coding for Reimbursement  Private Health Plans

 Medicare  Medicaid

Questions

Billing questions? Coding questions? Fee questions?