Billing and Coding: Speech-Language Pathology

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Speech-Language Pathology. General Guidelines for Claims submitted to Part A or Part B MAC: Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported. Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions. Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate. The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required. Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services. The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny. Documentation Requirements The patient’s medical record should include but is not limited to: The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit, Relevant medical history Results of pertinent tests/procedures Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.) The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Not only should documentation describe the condition of the patient that necessitates the skilled intervention of the speech-language pathologist, but should also report clinical judgment and describe the skilled nature of the treatment. Documenting the skilled components of activities will assist in supporting that the services are medically necessary. Documentation of speech language services, like other therapy services, must be objective, clear, concise, and must show evidence of the beneficiary's progress in meeting treatment goals. Documentation in the clinical record must be descriptive, clearly related to functionality, and complement and correlate with other disciplines. Medical necessity may not be established if there is conflicting documentation between disciplines or widely fluctuating abilities indicating an unstable condition. Prior level of functioning must be documented and considered in the patient's treatment plan, to establish reasonable goals for the patient's present condition. Statements such as "mildly impaired to moderately impaired" or "fair plus to good minus" do not offer sufficient objective and measurable information to support progress and may result in denial of services as not medically necessary. Documentation of discharge planning should be indicated early in the treatment plan. Where a valid expectation of improvement existed at the time services were initiated, or thereafter, the services may be covered even though the expectation may not be realized. Progress reports must document a continued reasonable expectation that the patient's condition will improve significantly, i.e., a measurable and substantial increase in the patient's level of communication, independence, and functional competence compared to the level when treatment was initiated. Documentation should include improvements, setbacks, and intervening medical complications—whatever is deemed pertinent to justify the need for continued intervention. For additional information on Medicare documentation requirements for speech-language pathology services see: CMS Publication 100-02, Medicare Benefit Policy Manual , Chapter 15, Section, 220, including the subsections under Section 220.