Can They Make Me Do That?Is It Even Ethical? ASHA experts answer members’ questions about sticky situations in billing Medicaid, Medicare and private health plans. Overheard
Overheard  |   March 01, 2015
Can They Make Me Do That?
Is It Even Ethical?
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Practice Management / Professional Issues & Training / Overheard
Overheard   |   March 01, 2015
Can They Make Me Do That?
Is It Even Ethical?
The ASHA Leader, March 2015, Vol. 20, online only. doi:10.1044/
The ASHA Leader, March 2015, Vol. 20, online only. doi:10.1044/
A school asks a speech-language pathologist to sign off on treatment provided by a clinical fellow … an inpatient facility asks a staff SLP to alter billing codes to capture more revenue … a supervisor tells SLPs to record evaluations as 15 minutes, and the rest as “therapy” minutes …
Many clinicians face these and other questionable asks. Three ASHA experts—Heather Bupp, director of ethics; Laurie Alban Havens, director of private health plans and Medicaid advocacy; and Lisa Satterfield, director of health care regulatory advocacy—fielded members’ questions about ethical billing in an online chat. The Leader was there.
Participant 1: My school system wants me sign off on treatment provided by a clinical fellow so they can bill Medicaid. Can I do this?
Laurie Alban Havens: That depends—are you supervising the CF? If questioned, would you be able to speak to the work that has been done? It’s not unreasonable to do this, providing that you have knowledge of the treatment that’s been provided.
Heather Bupp: It can be ethically risky to sign off on another practitioner’s work, particularly for a CF. The timing of it makes a big difference. The inquiries that I receive with facts similar to what was described here varies widely, from those signing off on therapy provided in a previous school year to therapy provided last week. In both cases, the CF no longer is available or working in the school district. The Board of Ethics Issues in Ethics statement “Responsibilities of Individuals Who Mentor Clinical Fellows in Speech-Language Pathology (2013)” clearly covers what is required with respect to supervision of a CF, and the “Ethics and Schools Practice” statement addresses the issue of signing off for another.
Laurie’s follow-up question about supervision is key. ASHA’s Code of Ethics provides guidance for the SLP confronted with conflicting information or differing opinions that can trigger ethical dilemmas. SLPs must be very firm yet cautious when dealing with administrators who direct them to “sign off” for services not rendered, such as those of service providers not supervised. It is important to share with the administrators the consequences for violations of the rules and regulations set by Medicaid. Services not adequately supervised and claims for services not provided could result in a school district having to repay Medicaid funds received for such services. In addition, fraudulent billing is a criminal activity that may be punishable by law, not only for the school district but also for the SLP participating in the activity. For additional information on this topic, visit the ASHA website for “Medicaid Guidance for School-Based Speech-Language Pathology Services: Addressing the ‘Under the Direction of’ Rule”.
Participant 2: I receive many comments from SLPs telling me that their company has taken away their ability to bill for 97532 (cognitive treatment). I have also been told that many SLPs are told they are not allowed to bill 97532 for people with dementia, since it is not expected that their cognition will improve. I have argued that both of these instances are wrong, as they do not reflect that actual treatment is being provided in many instances.
Lisa Satterfield: Of course 97532 is within the scope of practice for the SLP and should be billed when providing cognitive treatment. The dementia/cognitive issue is being discussed at ASHA. As for Medicare policy, there are some regional inconsistencies that have caused denials of 97532, but we are working to get that cleared up.
Havens: There are also some payers that just don’t accept 97532. We continue to advocate for its coverage. But ultimately, you need to let the payer know what it is you’re doing and how it should be billed.
Bupp: In complaints before the Board of Ethics, code uses are not usually at issue. During an audit, however, the codes become much more relevant.
Participant 3: My facility wants me to change (add) billing codes in an attempt to capture more revenue. Can I do this?
Bupp: That is, at minimum, unethical, if the sole basis for code changing or adding is to increase revenue. If the change/add also makes the treatment provided more accurately billed, that would be an exception.
Satterfield: Did you perform the service? Everything you do must have documentation to justify it. If you are unable to document it, you are unable to bill it. Medicare does allow you to amend notes, especially for G-codes, but the amendment must be clear and not an addition of services, but a clarification of what was provided.
Participant 4: Some of the questions we struggle with in terms of billing are the difference between a screening and diagnostics, and where does an evaluation end and treatment begin? For example, if we use the Burns Inventory in Acute Care (a screening tool), can this be used as part of a diagnostic? When we evaluate compensatory strategies for a swallowing evaluation and determine that a strategy is effective, is that considered a part of intervention or diagnostics?
Havens: I often recommend that if you’re in a setting with more than one clinician, that you come to an agreement on what comprises your evaluation versus your treatment.
Satterfield: Medicare defines “evaluation” and “assessment” differently, which may help you. An assessment is an extension of treatment. Assessments are not separately billable and are part of the skilled services delivered during a treatment session. Evaluation is a comprehensive service that determines a patient’s functional abilities, and it has an associated reimbursement code. Cognitive evaluations must include standardized testing, and can also include objective and subjective measures. Assessments also include subjective and objective measures, but not necessarily cognitive testing and they will be a part of treatment, not billed.
Participant 5: I understand the ethical issue of billing for what you did, and not for the code that will get you higher rate. But what about the reverse—is it ethical not to bill for higher-paying service when that service requires prior authorization and just continue to bill therapy with ongoing assessment?
Havens: If prior authorization is required, you need to get that. Not billing for something that is done is equally as wrong as billing for something that is not done.
Satterfield: For Medicare you have to bill for the services, or it is considered inducement.
Participant 6: What is inducement?
Satterfield: It is trying to get patients by offering incentives that are worth more than $50. You are not supposed to offer gifts to Medicare patients, and free services would be considered a gift.
Bupp: The general rule is that any gift that is “de minimis” is okay, even under government ethics. De minimis usually equals less than $50 over the course of a year. I recommend that you read Board of Ethics Issues in Ethics statement: Representation of Services for Insurance Reimbursement, Funding, or Private Payment (2010). It has specific references to the rules and principles of the Code of Ethics (2010r).
Participant 7: It is my understanding that CPT 92507 [treatment of speech, language, voice, communication, and/or auditory processing disorder] is an untimed code. In private practice, a family will not pay the same amount for a 30-minute session as they will pay for a longer session. What are the options available to us? What discounts are allowable? If the family does not demonstrate financial need, what options are there?
Bupp: The simplest concept to ethics and billing is that the more accurate the billing is to the services actually provided, the less likely anything can be found amiss. Of course, there are myriad billing oddities in Medicare and Medicaid that our members must deal with every day.
Havens: An ASHA Leader article on billing policies from 2006 addresses policies.
Participant 8: Is a digital copy of your signature sufficient on progress notes and evaluations in an outpatient speech therapy setting?
Satterfield: Electronic signatures can be used if they can be verified. They also must be dated. Make absolutely sure it is a verified signature, especially with the physician signature on the plan of care. There is a lot of attention on appropriate signatures for plans of care for outpatient therapy services right now. That physician signature is absolutely necessary!
Participant 9: Is a physician signature required on all evaluations not just Medicare?
Satterfield: To clarify, the physician signature is required on the plan of care, not the evaluation, for Medicare.
Participant 10: The therapist’s signature is on file and verified by the therapists that this is her/his signature. Is this the verification needed?
Satterfield: The CMS/Medicare guidelines for electronic signature are: 1) system must include protections against modification of the signature and 2) the individual still bears the responsibility of authenticity of the information. There is a reference to special requirements for prescriptions.
Participant 11: Would private practice be considered to be the same setting as outpatient SLP services? Outpatient SLP services would be connected to a hospital or other medical facility, correct?
Satterfield: Private practice and outpatient SLP services are the same in Medicare, called Part B services. Even if they are connected to a hospital or medical facility, outpatient services fall under the Part B Medicare benefit and have the same rules regarding documentation, therapy caps, manual medical review, and G-codes.
Participant 12: What about for private insurance with pediatrics?
Havens: Depending on the type of insurance, you indicate that provider type according to the how the insurer wants you bill for the service.
Participant 13: In private practice, with private insurance, does a doctor have to sign off on each plan of care?
Havens: Each insurance is different. I suggest checking with the provider procedural manual to find out the requirement.
Participant 14: We are aware that we should bill speech-language as our primary diagnosis code. Our problem is a child with a primary diagnosis of 299.0 [autism] and a secondary of 315.39 [other developmental speech or language disorder] or 315.32 [mixed receptive-expressive language disorder]. The insurance system rejects the claim automatically if there is a 315.39 code, so the insurance company we work with instructed us to just leave off the 315.39 and 315.32 because the child gets speech services under 299.00. Does this sound ethical?
Havens: The 315 code would not be used with the 299, because it is a condition that has an underlying organic cause. It would be more appropriate to bill 784.69 [verbal dyspraxia] or 784.59 [other speech disturbances] potentially. I’d need to know more details about the exact condition. For most payers, you list what you treat first, and the underlying cause second.
Participant 15: Why would the 315 codes not be used with 299.0 code?
Havens: The 315 series are considered to be developmental, without a specific organic cause. The 784.69 is other symbolic dysfunction with an organic cause for the condition.
Participant 16: Can you bill separately for a dysarthria and a voice evaluation or at that point, should we billing for a comprehensive evaluation?
Havens: The codes for speech (92522) and voice (92524) can be used. The 92506, which was the comprehensive evaluation code, was retired at the beginning of this year, so you would bill for the condition(s) evaluated.
Satterfield: You are right to be concerned about billing too many codes in a session and we have discouraged that. However, the new evaluation codes are divided by fluency, speech/language, and voice, and when those services are each evaluated comprehensively, it is ok to bill those codes on the same day. Also what you should NOT do is perform a comprehensive speech/language with a tiny bit of voice assessment. Your voice assessment should be comprehensive, with objective and subjective findings, and recommendations (normal, or continued treatment, etc.).
Participant 17: Is there ever a situation in which an SLP can provide services for free?
Satterfield: For Medicare purposes, you have to offer your services for free for every single patient—regardless of insurance. If you offer them to one, you have to offer to all … you cannot pick and choose based on insurance.
Bupp: This is a question that I receive quite often. Providing speech-language therapy pro bono or free is definitely ethical and legal. The provision of services cannot be made, however, in a substandard manner simply because the patient is not able to pay and/or the clinician is not going to be reimbursed. All of the usual safeguards and ethical obligations apply, competency, confidentiality, supervision (if applicable), etc.
Satterfield: Medicare requires that your published fee schedule is consistent, and that any sliding scale is based on need, income, or other qualifications that are not discriminatory or not based on insurance.
There is a difference between your published rate and what you contract with insurance companies to accept as payment in full, and that is often confused. Your published rate for 30 minutes of therapy may be $100, but Medicare contracts with you to accept payment in full at $60. That is ok.
Havens: You can also refer to the article on “Billing Policies: What’s Legal, What’s Not” that I cited earlier.
Participant 18: How do things work ethically/legally for pro bono services—for example, if one provides monthly advice sessions on swallow issues/oral hygiene for a hospice or a “street clinic” for the homeless?
Havens: Those services aren’t considered direct therapy, and it is acceptable to provide that type of information for a group.
Bupp: Providing free educational or consumer information sessions may not necessarily be considered treatment or therapy.
Participant 19: It is evident that some Medicaid insurances will not authorize speech treatment three times a week. I had two patients with autism, one severe intellectually impaired patient, and one severely unintelligible 4-year-old denied 3x/wk frequency. How do I document that these children need frequent and consistent treatment? A justification for frequency of service was sent and insurance still denied.
Havens: That is obviously unfortunate. We encourage appealing situations like this if you are able, and we have resources to assist with that. With insurances, you need to state the need, and extenuating situations. You also want to be careful that you’re not making that request for everyone. Ultimately, you need to find out how many sessions are allowed, and identify what you can accomplish within that timeframe, including training others, e.g. parents, caregivers, if that can be incorporated in the program.
Bupp: From a purely ethics standpoint, advocating for your client is exactly what you should be doing, and using your independent professional judgment is required under Principle of Ethics IV, Rule J of the Code of Ethics (2010r): “Individuals shall not provide professional services without exercising independent professional judgment, regardless of referral source or prescription.”
Participant 20: Can an evaluation [92521–92524) be billed on the same day as treatment 92507? Likewise, can device programming 92609 be billed on the same day as treatment 92507? Is this ok if the session on that day is divided between the two services?
Satterfield: Generally, evaluations can be billed on the same day as treatment. You must be able to document the distinct services that were provided that day, along with the time. However, 92609, therapeutic services with speech-generating device, can only be billed with 92507, treatment of speech, language—if you are able to distinguish between the two and use a -59 modifier. Session codes are tough, so you do need to make absolutely sure those services are separate, and even though you don’t report time on the claim, you need to include the time spent in your documentation.
Participant 21: My supervisor keeps asking me to record my evaluations as 15 minutes, and the rest as “therapy” minutes. This doesn’t seem right to me—is it?
Satterfield: Very common question. First, let me clarify that Medicare does not limit the time for evaluations—that is an administrative decision. For skilled nursing facilities especially, the daily rate includes the evaluation time, but the payment is supplemented only by the number of treatment minutes, and more treatment minutes equal more payment.
Bupp: Instructions from administration or staff to limit evaluation time may be an indirect way of reminding clinicians to maximize therapy time (for example, in an hour session, 45 minutes would be counted as therapy if the clinician did a 15-minute evaluation). If clinically appropriate, treatment can be performed on the same day as an evaluation and counted toward the therapy minutes.
Satterfield: Your evaluation first and foremost should be clinically appropriate. Evaluation and treatment can occur on the same day, and assessment can be counted in therapy minutes, but make sure your evaluation is comprehensive and documented accurately, including your time.
That has been brought up in several meetings, especially as Congress and Medicare look to episodic payment models. However, Medicare A (inpatient/facility) does not charge separately for the evaluation, and they get paid for the evaluation through the daily rate, not separately. So there isn’t actually an associated charge of $100 for 15 minutes, for example, just a notation of time.
Participant 22: We work with children with various severe disabilities autism, cerebral palsy, brain injury). We are often told by our therapists that the definition of medical necessity is vague. Creating longer utterances, expressing opinions on a topic, supporting rationale, etc.—are these medically necessary? Is there any way to verify what might be considered medically necessary? Also, how does this work? Do the insurance companies come back a year later and question whether treatment already provided/billed/paid was medically necessary?
Havens: There is a federal statement as to what is medical necessity and many states follow that. However, about one-fourth of the states have their own definitions. I recommend that clinicians look to see if there’s a definition for their state specifically and determine how what they’re doing fits that statement. The association of state health plans has a link to this.
Satterfield: The Medicare Benefit Policy Manual defines services as medically necessary if they are “skilled, rehabilitative services provided by clinicians (or qualified professional when appropriate) with the approval of a physician or non-physician practitioner (clinical nurse specialist, PA, nurse practitioner), safe, and effective (i.e., progress indicates that the care is effective in rehabilitation of function).”
Participant 23: Are there specific legal guidelines that have to be in place to apply sliding fee scales for private-pay clients? Is there specific financial information that needs to be collected? Is it company-specific?
Havens: You should state what your policies are for making that determination. I’d recommend consulting with your attorney/accountant in setting business practices/requirements.
Bupp: 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 indigence. Contact local welfare clinics to learn the community standard. Medicare/Medicaid allows for limited documented indigence.
Participant 24: For a full/comprehensive evaluation, I am simply going off of the reason for referral (for coughing, a dysphagia bedside swallow evaluation with oral motor exam and a quick cognitive screen; for memory, a standardized cognitive test [BCAT, RIPA-G, etc.]) with no official doctor’s orders unless something in the history and physical makes me inquire about another area. But if I feel the need to look at another area such as language-during the initial evaluation but might be running short on time—or don’t have objective measure/standard evaluation—what would be the process? Finish the initial evaluation with results, then continue treatment while documenting the need for a language evaluation?
Satterfield: For Medicare, the services actually don’t turn on the physician order, but rather on the plan of care that is signed by the physician and established after the comprehensive evaluation. Your facility may have other processes which include the order of the physician, so coordination with the medical team would be a good place to start.
You can also perform an evaluation over a couple of days, just be careful how you bill. For example, if you start the cognitive evaluation on day one, but are unable to finish it and continue it to day 2, only bill for the final day when you were able to obtain all of the information necessary to determine your plan of care.
Participant 25: What if you bill for the evaluation on the first day and write in your goals to complete additional assessment of specific areas as part of your plan of care at subsequent sessions and then charge as treatment?
Satterfield: If you have enough information after the evaluation to write the plan of care, you can do that. Your evaluations need to provide enough information to write a full plan of care, including treatment goals. Follow-up assessment as a part of treatment should supplement the treatment, not the evaluation.
Participant 26: What if a client would like to provide a monetary gift to the clinician out of their own pocket? Can this be accepted?
Bupp: If a client would like to provide a monetary gift to the clinician out of his own pocket, it should not be accepted. This is because it is a conflict of interest. Inherently, there is a power differential between a client/patient and a clinician. Although there are exceptions to the rules against accepting gifts, such as the rule that I mentioned earlier, I discourage a clinician from accepting even a small gift. The clinician must keep the relationship professional at all times.
Participant 27: Are there any treatment codes that include documentation time? If not, how ethical is it to do point-of-service documentation in a treatment session?
Satterfield: Nope, the treatment codes have time factored in them.
Havens: Is your documentation including statements that you are making to the patient simultaneously about the treatment, so that you’re reviewing the treatment with them? That could be acceptable.
April 8, 2015
Kelly Manuszak
cognitive eval/therapy
If we complete a cognitive evaluation using portions of a standarized test, we bill 96125? If we do 60 min of cog therapy, we bill for 97532 and specify 4 units since this is a timed code, correct? If we do an eval and then 10 min of cog therapy after the eval, can we bill both codes on the same day (only specifying 1 unit of 97532)?
April 9, 2015
Lisa Satterfield
Answer to cognitive billing questions
To bill 96125, the test or the individual subtests must be norm or criterion referenced ( Also the minutes of face-to-face time, interpretation, and report time must add up to at least 31 minutes in order to bill 96125 because it is a per hour code and more than half of the time must be reached in order to bill the code. Likewise, the cognitive treatment code 97532 is a per-15 code, so 4 units for a 60 minute session is the correct way to bill 97532 ( In order to bill 96125 and 97532 on the same day, you would need to make sure you performed a comprehensive evaluation including the standardized test (or subtest) and spent the 31 minutes doing so, then distinctly performed a minimum of 8 minutes of therapy (97532). You must have justification that supports billing two codes on the same date of service that would pass in the case of an audit.
February 15, 2017
billing feeding therapy as general speech therapy
Hi there, My facility is having speech therapists bill outpatient feeding therapy under general "speech therapy treatment" unless the private insurance company requires "swallowing treatment/oral phase" to be billed specifically. My feeling is that all therapies should be billed as reflective as services provided. If this is correct, is there a document I can provide my facility with to support this billing practice? Thank you.
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March 2015
Volume 20, Issue 3