Capturing Cognition in Skilled Nursing Facilities What SLPs need to know to correctly perform—and document—cognitive evaluations for Medicare beneficiaries. Bottom Line
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Bottom Line  |   December 01, 2015
Capturing Cognition in Skilled Nursing Facilities
Author Notes
  • Lisa Satterfield, MS, CCC-A, is director of ASHA health care regulatory advocacy. lsatterfield@asha.org
    Lisa Satterfield, MS, CCC-A, is director of ASHA health care regulatory advocacy. lsatterfield@asha.org×
  • Monica Sampson, PhD, CCC-SLP, is associate director of ASHA health care services. msampson@asha.org
    Monica Sampson, PhD, CCC-SLP, is associate director of ASHA health care services. msampson@asha.org×
Article Information
Special Populations / Older Adults & Aging / Healthcare Settings / Practice Management / Attention, Memory & Executive Functions / Bottom Line
Bottom Line   |   December 01, 2015
Capturing Cognition in Skilled Nursing Facilities
The ASHA Leader, December 2015, Vol. 20, 32-33. doi:10.1044/leader.BML.20122015.32
The ASHA Leader, December 2015, Vol. 20, 32-33. doi:10.1044/leader.BML.20122015.32
Increased billing scrutiny from Medicare contractors and the Office of the Inspector General has speech-language pathologists on edge—especially for claims related to evaluating for cognitive disorders. If you know the answers to the following questions, you are on the right track!
Who should be evaluated?
Medicare Part A (inpatient) will pay for speech-language services provided in skilled nursing facilities (SNFs) only for patients who have conditions that:
  • Were treated in the qualifying three-day inpatient hospital stay.

  • Were present during the qualifying three-day inpatient hospital stay.

  • Presented while the patient was in the SNF for treatment of a condition for which the patient was previously hospitalized.

Only those patients with hospital or current-stay documentation indicating the need for a cognitive evaluation should receive one. If you note patients who are not being appropriately referred, it is a good opportunity to talk with the physician and members of the care team about the need for a speech-language consult. An SLP’s evaluation can differentiate cognitive deficits from other changes in mental status, such as delirium, to help make sure the patient receives appropriate and necessary services.
How do I document the evaluation?
Inpatient (Part A) and outpatient (Part B) requirements for documentation and billing are different. It’s a best practice, however, to document according to Part B requirements in case the patient’s Part A coverage is denied. If, for example, a patient in the SNF has not met the three-day minimum inpatient hospital requirement for Part A eligibility, the facility could bill Part B for the therapy services you provide—but only if the services and the documentation are consistent with Part B standards.

It’s a best practice to document according to Part B requirements in case the patient’s Part A coverage is denied.

For a cognitive evaluation under Part B, SLPs use CPT code 96125 (Current Procedural Terminology ® American Medical Association), a timed code that requires a minimum total of 31 minutes for testing, interpretation and report writing. These times should be documented in the medical record.
An additional key component of billing CPT 96125 for a cognitive evaluation is the use of a standardized assessment, independently or in conjunction with subjective observations and findings.
What constitutes a standardized assessment?
Standardized assessments are empirically developed evaluation tools with established statistical reliability and validity. “Standardized” refers to the test administration procedure—they require all test-takers to answer the same items/questions in the same way and they are scored in a standard or consistent way, making it possible to compare the relative performance of individuals or groups of individuals.
What standardized assessments are appropriate for billing 96125?
Any standardized assessment tool (not identified as a screening tool in the test description) can be used to bill CPT 96125, as long as the combined testing, interpretation and report writing takes at least 31 minutes. Examples of appropriate standardized assessments include Ross Information Processing Assessment-Second Edition (RIPA-2), Arizona Battery for Communication Disorders of Dementia (ABCD), and Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES).
Can selected subtests of standardized tests (instead of the entire standardized assessment) be administered for billing 96125?
The CPT code description does not give specific guidance about administering only selected subtests. The clinician may give selected subtests from standardized test batteries to bill for 96125, as long as the individual subtests themselves have been standardized for independent administration. If the subtests have not been standardized in that manner, clinicians may use them to supplement the findings from a standardized test. However, the clinician cannot report the standardized scores from these subtests. Only subjective descriptions of the person’s functioning—which do not meet the “standardized assessment” criterion to bill 96125—can be reported in this case.
How do I know if Medicare will pay for the evaluation?
Each Medicare jurisdiction has Local Coverage Determinations that indicate which procedures and diagnoses are considered “medically necessary,” and therefore billable. The recent transition from the International Classification of Diseases, Ninth Edition (ICD-9) to ICD-10 is causing some difficulties in obtaining reimbursement, especially in regions administered by the Medicare contractor National Government Services (NGS). ASHA is looking into these difficulties and hopes to help resolve them.
If you are having problems with Medicare claims for cognitive services, contact the Health Care Economics & Advocacy team at reimbursement@asha.org. If you have questions about cognitive assessments, contact the Speech-Language Pathology Health Care Services team at healthservices@asha.org.
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December 2015
Volume 20, Issue 12