How Services Are Valued: A Guide to Reimbursement Fair reimbursement rates are vital to speech-language pathologists and audiologists providing services in nearly every setting, from private practice to outpatient hospital settings. Clinicians benefit from understanding how reimbursement codes are valued by the payers, a determination that ultimately establishes the payment you receive for the services you provide. ... Bottom Line
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Bottom Line  |   June 01, 2009
How Services Are Valued: A Guide to Reimbursement
Author Notes
  • Robert Fifer, PhD, CCC-A, is associate professor and director of audiology and speech-language pathology at the Mailman Center, University of Miami.
    Robert Fifer, PhD, CCC-A, is associate professor and director of audiology and speech-language pathology at the Mailman Center, University of Miami.×
  • Janet McCarty, MEd, CCC-SLP, is ASHA’s private health plans advisor.
    Janet McCarty, MEd, CCC-SLP, is ASHA’s private health plans advisor.×
  • Steven White, PhD, CCC-A, is ASHA’s director of health care economics and advocacy. For more information on reimbursement, visit the ASHA Web site.
    Steven White, PhD, CCC-A, is ASHA’s director of health care economics and advocacy. For more information on reimbursement, visit the ASHA Web site.×
Article Information
Practice Management / Bottom Line
Bottom Line   |   June 01, 2009
How Services Are Valued: A Guide to Reimbursement
The ASHA Leader, June 2009, Vol. 14, 1-2. doi:10.1044/leader.BML.14082009.1
The ASHA Leader, June 2009, Vol. 14, 1-2. doi:10.1044/leader.BML.14082009.1
Fair reimbursement rates are vital to speech-language pathologists and audiologists providing services in nearly every setting, from private practice to outpatient hospital settings. Clinicians benefit from understanding how reimbursement codes are valued by the payers, a determination that ultimately establishes the payment you receive for the services you provide.
The Relative Value System
How does Medicare decide how much to pay for speech-language treatment code 92507? How does a private health plan determine the reimbursement rate for a comprehensive audiometric evaluation code 92557? Payment for outpatient audiology and speech-language pathology services is based on a system developed by the federal government for Medicare, and Medicaid and many private health plans have adopted this system.
The system strives to make payments for all medical procedures relative to one another so that if one procedure is twice as difficult as another, it will be paid twice as much. The system values procedures based on a number of components—professional expertise, time, support staff, depreciation of capital equipment, supplies, and malpractice insurance costs—in other words, the resources needed to provide the service. Therefore, the system is called a resource-based relative value scale.
The American Medical Association (AMA) established and owns and operates the Current Procedural Terminology (CPT) codes, but the federal government’s Centers for Medicare and Medicaid (CMS) assigns the values for each code. Each medical society, including ASHA, is allowed to provide data to be used to establish the value of a procedure code. The data are reviewed by the AMA Relative Value Update Committee (RUC)—but CMS has the final word.
Development and Valuation of Codes
The AMA develops and approves new and updated procedure codes with input from the health care community. CMS then values the procedures using recommendations from the RUC. Since 1992 the AMA has recognized ASHA as the representative for audiology and speech-language pathology. In this role, ASHA proposes and modifies CPT codes and provides input on value recommendations sent to CMS. ASHA sends an equal number of audiologists and SLPs to AMA meetings and works in collaboration with other audiology and speech-language pathology organizations and ASHA special interest divisions.
A new CPT procedure undergoes a valuation process. A medical society such as ASHA will survey a select number of its members to determine the professional work and expenses involved with providing that procedure—the procedure’s complexity and the expertise, time, supplies, and equipment required to provide the procedure. The survey asks about the physical and mental effort needed to provide the procedure, associated psychological stress, and the number of times respondents perform the procedure.
Other related societies also survey their members. For example, otolaryngologists often perform work surveys for codes that are of interest to audiologists and SLPs. All survey information is submitted to the AMA, which makes valuation suggestions to CMS. In the final step of the process, CMS determines the relative value of each procedure, which is then multiplied by a dollar conversion factor to yield a payment amount.
SLPs in private practice will benefit from recent legislation that recognizes SLPs as independent practitioners under Medicare. This change is the foundation that established the status of professional work for SLPs. However, a clinical bedside evaluation (92610) was reduced in 2009 because there is no professional work valuation for that code. Rather than have different practice expense formulae for different specialties, CMS decided to use a single formula to calculate practice expense. Speech-language pathology and some audiology procedures have suffered from that decision because many of those codes do not have professional work as part of the reimbursement calculation (see sidebar).
ASHA continues to advocate for equitable payment for audiology and speech-language pathology services, suggest codes for reevaluation when feasible, and establish new and revised codes when appropriate.
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June 2009
Volume 14, Issue 8