Crafting Reimbursement Codes Coding Process Requires Time, Effort, and Expertise Bottom Line
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Bottom Line  |   October 01, 2002
Crafting Reimbursement Codes
Author Notes
  • Nancy Swigert, an SLP, owns Swigert & Associates, Inc. and is head of the department of speech-language pathology at Central Baptist Hospital in Lexington, KY. Contact her at nswigert@aol.com
    Nancy Swigert, an SLP, owns Swigert & Associates, Inc. and is head of the department of speech-language pathology at Central Baptist Hospital in Lexington, KY. Contact her at nswigert@aol.com×
  • Robert Fifer, is an associate professor in the University of Miami School of Medicine’s pediatrics department and is director of audiology and speech-language pathology in the Mailman Center for Child Development. Contact him at rfifer@peds.med.miami.edu.
    Robert Fifer, is an associate professor in the University of Miami School of Medicine’s pediatrics department and is director of audiology and speech-language pathology in the Mailman Center for Child Development. Contact him at rfifer@peds.med.miami.edu.×
Article Information
Practice Management / Bottom Line
Bottom Line   |   October 01, 2002
Crafting Reimbursement Codes
The ASHA Leader, October 2002, Vol. 7, 3-28. doi:10.1044/leader.BML.07182002.3
The ASHA Leader, October 2002, Vol. 7, 3-28. doi:10.1044/leader.BML.07182002.3
Audiologists and speech-language pathologists who work in clinical settings are familiar with Current Procedural Terminology (CPT)™ codes. They may have a list of codes prepared by their facility or may even have the CPT book itself in their office. Most have wished at one time or another for more codes or for a code that better describes the procedure they have performed. Is it possible for those wishes to become reality? Yes, but it is neither an easy nor expeditious process.
The CPT process, owned by the American Medical Association (AMA), involves multiple steps. New procedures must be approved by two separate AMA panels. This process can take 11–18 months before new codes appear in the CPT manual. ASHA’s participation in this process is assigned to the Health Care Economics Committee (HCEC). The HCEC consists of five audiologists and five SLPs and is monitored by Larry Higdon, vice president for governmental and social policies. The committee is chaired by Wayne Holland and currently includes vice chair Walter Smoski, Thomas Rees, Robert Fifer, Connie Barker, Gwenlynn Reeves, Dee Adams Nikjeh, Nancy Swigert, and National Office ex officio Steven White.
“For appointment to the HCEC, it is important to identify members who are actively involved in third-party billing and who are sensitive to billing needs of colleagues and consumers,” Higdon says. He added that the committee also looks for members who have a broad understanding of the reimbursement needs of the professions.
Last year the committee moved 17 procedures from start to finish, and these will appear in the CPT 2003: Current Procedural Terminology, Fourth Edition. Four procedures focused on cochlear implant programming, five were AAC procedural codes, and eight were dysphagia codes for clinical and instrumental assessments. The dysphagia codes include bedside/clinical evaluation, videofluoroscopic evaluation, and six codes for endoscopic evaluation. Three of the dysphagia endoscopic assessment procedures are designed to be used by the SLP, and three additional codes include participation of a physician in the evaluation.
The first step in the process was presenting the codes to the AMA CPT Panel. The panel is comprised mostly of physicians, representatives from the insurance industry, and representatives from the Centers for Medicare and Medicaid Service (CMS). All non-physician groups are represented by one professional who is elected by the Health Care Professional Advisory Committee (HCPAC), an AMA CPT subcommittee of which ASHA is a member. Holland represents ASHA on the CPT HCPAC.
Several members of the HCEC who have expertise in the codes being presented are assigned to guide a code or set of codes through the multiple-step process. One or two members of the team attend the CPT meeting. Prior to making a formal presentation to the panel, these team members work behind the scenes with other interested groups who might use the codes.
“Consensus building is imperative to this process,” Holland says. “For example, ASHA often collaborates with the American Academy of Otolaryngology–Head and Neck Surgery before taking codes forward for consideration.” Codes in the CPT manual are not discipline-specific, but may be used by any qualified health care professional.
Sometimes procedures are being presented for which there are no members of the HCEC with specific expertise. When that happens, other ASHA members are called upon to serve as expert consultants to the committee. Last year the committee called on Carolyn Wiles Higdon, an expert in AAC, when the codes for evaluation and therapeutic services for augmentative devices were addressed. Wiles Higdon accompanied members of the committee to the CPT meeting and presented a strong case for passage of five new codes. Her participation convinced her that ASHA members need more education and training about their role in the coding process.
“Only practicing clinicians can supply the valuable data we need to prove that an existing code needs to be changed or that a new code needs to be added,” she says.
Once the codes are approved by the AMA CPT Panel, they must then be assigned a value. Presentations were made several months later to the AMA Relative Value Update Committee (RUC) regarding the work and practice expense associated with each procedure.
Many of the codes used by our members have a physician work component that increases the value of the code. The physician work component makes it essential that consensus is reached with all interested physician societies before the meeting. ASHA members also must supply data about these procedures so that expenses can be accurately reported. For example, members of Division 13, Swallowing and Swallowing Disorders were surveyed about their use of these procedures.
Division 13 coordinator Paula Sullivan says, “I was pleased to discover that the data-gathering process is standardized, systematic, and evidence-based to ensure that providers across settings are fairly reimbursed.” Sullivan also served as a consultant to the HCEC and attended the RUC meeting to advocate for the values of the new FEES/FEEST codes.
Like the CPT Panel, the RUC is comprised mostly of physicians, although a CMS representative sits on the committee, participates in discussions, and participates in the AMA decisions determining the value of each code. The RUC also has a HCPAC, which selects one person to represent all non-medical groups on the RUC. Smoski, past chair of the HCEC, is ASHA’s current representative on the RUC HCPAC.
Committee member Fifer presented the data for the cochlear implant procedures while Wiles Higdon presented the AAC data to the RUC HCPAC. The time associated with each of the procedures for both cochlear implant programming and AAC were questioned, but Fifer and Wiles Higdon explained each minute of each procedure, resulting in success for ASHA.
After the AMA renders its decision on the value of work and practice expense, CMS then revalues each procedure according to its standards. These standards were established by Congress to pay for health care services to Medicare Part B beneficiaries. In essence, Congress designated a fixed pot of money from which all services must be paid. Because some services are more expensive to provide or carry greater risk than others, a resource-based relative value scale was established to rank the value of all codes for reimbursement. In recent years, these relative values have been adopted as the framework of reimbursement for many private insurers and HMOs.
In addition to the CPT Panel and RUC, there is one other process in which the HCEC is actively involved. This is the process of reviewing all existing codes to determine if the assigned practice expense values are accurate. This process is assigned to a sub-committee of the RUC called the Practice Expense Advisory Committee (PEAC). Based on surveys of members and advice from member expert panels, committee members Swigert and Nikjeh presented information to the PEAC in mid-September on speech-language pathology codes 92506, 92507, 92526, and 92508; Fifer and Rees presented information on audiology codes 92561, 92562, 92563, and 92464. All the audiology and speech-language pathology codes passed review by the PEAC.
For more information about the coding process, contact Steven White through the Action Center at 800-498-2071, ext. 4126, or by email at swhite@asha.org.
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October 2002
Volume 7, Issue 18