Imagine My Surprise: Lessons Learned When a Health Plan Asks for Repayment Having run a small practice for 25 years, I used to think of myself as knowledgeable about coding for speech-language pathology services. I’ve given workshops at other speech-language pathology clinics as well as to university classes on coding for our services. I presented at an ASHA Convention on the differences ... In Private Practice
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In Private Practice  |   June 01, 2007
Imagine My Surprise: Lessons Learned When a Health Plan Asks for Repayment
Author Notes
  • Kathleen Helfrich-Miller, is a speech-language pathologist who has been in private practice in the Pittsburgh area for the past 25 years. She is the owner of Rehabilitation Specialists, Inc., and also serves as an adjunct faculty member for the University of Pittsburgh and Duquesne University. Contact her at kathleen.miller54@verizon.net.
    Kathleen Helfrich-Miller, is a speech-language pathologist who has been in private practice in the Pittsburgh area for the past 25 years. She is the owner of Rehabilitation Specialists, Inc., and also serves as an adjunct faculty member for the University of Pittsburgh and Duquesne University. Contact her at kathleen.miller54@verizon.net.×
Article Information
Speech, Voice & Prosodic Disorders / Practice Management / Regulatory, Legislative & Advocacy / ASHA News & Member Stories / In Private Practice
In Private Practice   |   June 01, 2007
Imagine My Surprise: Lessons Learned When a Health Plan Asks for Repayment
The ASHA Leader, June 2007, Vol. 12, 18-19. doi:10.1044/leader.IPP.12082007.18
The ASHA Leader, June 2007, Vol. 12, 18-19. doi:10.1044/leader.IPP.12082007.18
Having run a small practice for 25 years, I used to think of myself as knowledgeable about coding for speech-language pathology services. I’ve given workshops at other speech-language pathology clinics as well as to university classes on coding for our services. I presented at an ASHA Convention on the differences among coding systems, stressing the need for speech-language pathologists to understand health system coding.
Imagine my surprise when, in February 2006, two representatives from Highmark Blue Cross & Blue Shield scheduled a meeting with me to discuss the “inappropriate use of codes” for speech-language pathology billing and requested a large sum of money be returned to them for overpayment of services for a period that spanned 2003 to 2005.
At issue was the coding for 92506 (speech-language evaluation), 92507 (individual speech-language treatment services) and 92508 (group speech-language treatment services). In the Current Procedural Terminology (CPT) manual published by the American Medical Association (AMA), these codes by definition do not have a time component associated with them. They are billed per “face-to-face encounter.” Our clinic billed these codes by complexity which, we concluded, ultimately involved time.
Defining a Session
Also, there was an issue around the definition of a “session” of speech treatment. Nowhere is there a definition of what constitutes a “session” of speech treatment. ASHA does not define a session, nor do private insurance plans. Our clinic defined a session as one component of a treatment encounter, recognizing that an SLP may treat multiple components of a speech-language disorder during one encounter. We billed this as a “unit” of service with one unit representing one session.
To communicate with its providers, Highmark uses a Web-based program called “Navinet.” On this Web site, Highmark states in the Procedure Code Details for Codes 92506, 92507, and 92508, under procedure frequency, that services may be billed “multiple times on one day.” Billing for multiple sessions on one day has been the “usual and customary practice” of freestanding (non-hospital-based) outpatient speech treatment providers for more than 20 years. We billed, and Highmark paid, for services billed in this fashion.
Based on a special, rather undefined, speech treatment project, Highmark decided its computers had made an error in how it paid claims. Payment had to be made based specifically on the definition of the CPT codes. HIPAA requires medical billing to be consistent with CPT policy; thus, designating time units is not allowed if no time units are part of the CPT definition. Other clinicians indicate that payers are increasingly following this directive, even if previous policy was to allow time unit designations.
Grievance Procedure
One should always read the “fine print” of contracts. After Highmark denied our first appeal, our only option was to file a grievance with Highmark’s Medical Review Board, whose decision would be final. Further research confirmed Highmark’s authority in this matter, based on the language written into the provider contracts. Our meeting with the Medical Review Board took place, ironically, on the hottest day of the year in Camp Hill, Pa. After hearing our testimony, the review board was supposed to make a decision (approximately 10–15 minutes of deliberation) before moving on to its next case. Subsequently, it had 30 days to inform us of the decision.
The review board decided it needed more information and asked to see our medical records. The records were to be reviewed by Highmark staff and consultants. We requested that an SLP review the records and Highmark complied.
Internal Review Results
The results of the internal review of our records found that all documentation was “appropriate, concise, and comprehensive” and that diagnosis codes “were used correctly.”
However, the internal review results went on to say that ASHA agreed with Highmark and attempted to use ASHA’s information pertaining to Medicare as their justification. Apparently, Highmark accessed a 2001 ASHA Leader article (available to the public) titled “Is There A 15-Minute Billing Code In Our Future?” The article reports that for the past six years Medicare, and likely private payers, require “billing based on strict” CPT descriptors, which contain no time designations.
In our second meeting with the Medical Review Board—on the coldest day of the year—a letter was submitted by Mark Kander, ASHA’s director of health care regulatory analysis, which clarified the message in ASHA communications about codes and time units. After a long discussion that centered on the definition of codes rather than on quality and appropriateness of the treatment provided, the review board made its final decision. Based on a December 2004 article in the AMA’s CPT Assistanttitled “Coding Communication: Special Otorhinolaryngologic Services” that defined the CPT codes as untimed codes, we had to pay back one-third of the money as an overpayment.
The review panel believed that since this was the first time there was printed guidance for CPT coding for speech-language services, the repayment period would be from the article date forward. I’m uncertain how many SLPs have access to this publication. I certainly don’t.
The whole process left me wary of a health care system that polices itself and aware that our national organization should teach private insurers the value and complexity of our services. ASHA should continue to improve access and usability of the Web site for obtaining information on reimbursement and billing. I also believe universities should teach students the mechanisms on reimbursement and health care coding.
The bottom line is that clinicians should know medical coding systems and also not be afraid to have their voices heard.
How To Avoid Health Plan Repayments
Know CPT Codes

CPT codes define treatment procedures, and it is possible to have several procedures performed at one time. For example, a speech-language treatment session followed by a swallowing treatment session would be coded as 92507 and 92526. Thus, a session could have multiple components defined by different CPT codes, but not defined in terms of a unit of time, if the procedure code has no designated time unit. A session generally refers to an encounter, or visit. Time units can be billed only when the procedure code actually designates time units.

Know HIPAA Billing Requirements

HIPAA requires medical billing to be consistent with CPT policy. Designating time units is not allowed if time units are not part of the CPT definition.

Know Medicare Billing

Medicare billing, and likely private payers, require billing based on strict CPT descriptors, which for many speech-language procedure codes contain no time designations.

Access ASHA Reimbursement Information

ASHA provides members with information on reimbursement through how-to guides, brochures, and other resources. ASHA’s Web site on reimbursement and billing provides information on payment, claims, codes, regulations, and advocacy. ASHA continually works to make the Web site user-friendly and recognizes the challenge with so much information to disseminate. ASHA provides workshops on reimbursement throughout the country, and has several member networks to assist with regional payment issues. ASHA also continually communicates with payers, employers, legislators, and coding decision-makers about payment for members’ services. The ASHA Leader publishes articles on reimbursement topics that are current at the time of publication. Up-to-date reimbursement information is available at ASHA’s Reimbursement Web site.

For further information, contact Janet McCarty at jmcarty@asha.org.

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June 2007
Volume 12, Issue 8