Coding and Billing 101 Diagnosis and treatment codes required for billing can be confusing for new audiologists and SLPs. Some basic information eases the learning curve. Bottom Line
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Bottom Line  |   October 01, 2017
Coding and Billing 101
Author Notes
  • Kate Ogden, MPH, is a former ASHA health policy associate.
    Kate Ogden, MPH, is a former ASHA health policy associate.×
Article Information
Practice Management / Attention, Memory & Executive Functions / Bottom Line
Bottom Line   |   October 01, 2017
Coding and Billing 101
The ASHA Leader, October 2017, Vol. 22, 34-36. doi:10.1044/leader.BML.22102017.34
The ASHA Leader, October 2017, Vol. 22, 34-36. doi:10.1044/leader.BML.22102017.34
New clinicians start their careers brimming with clinical knowledge, ready to work with clients and patients. But they often are unprepared for the realities of dealing with insurance companies, determining the correct diagnosis and treatment codes to put on a claim form, or making sure they comply with the many regulations related to health care payment.
Here are some basic coding and reimbursement tips and resources to help students and new clinicians get started.
My job doesn’t require me to work directly with insurance or coding. Why should I worry about it?
Ignorance is not bliss! It is ultimately your responsibility—as the clinician providing treatment—to be aware of relevant payment policies, rules and regulations. You are at risk for charges of fraud or abuse if you make mistakes, even if they are innocent mistakes because you were unaware of the rules. Your name goes on the signature line as the rendering provider, so it’s important for you to be confident that you have provided and documented your services appropriately (see “How to Keep Ethically Clean in Reimbursement”).
Where do I even start to learn about the rules and regulations that affect me?
Start by understanding what payers you and your workplace deal with. Each payer may cover or deny different services and can have different rules for documentation, supervision and billing.
Medicare is the federal health insurance program for people who are 65 and older or who are permanently disabled. There are four “parts” to Medicare. Part A covers inpatient services provided in hospitals and other facilities (including skilled nursing facilities and long-term care hospitals); the facility receives a lump payment for all the services it provides. Part B covers outpatient services on a fee-for-service basis, including those provided in private practices or university clinics. Part C—or Medicare Advantage—includes privately managed plans that are required to cover all Medicare benefits (for example, BlueCross Medicare Advantage). Part D is the prescription drug benefit.
Medicaid is a state-based program funded jointly by states and the federal government. Beneficiaries include low-income families and children, pregnant women, the elderly, and people with disabilities. Medicaid in your state may not be called “Medicaid”—in Oklahoma, for example, Medicaid is “SoonerCare.” Medicaid rules and regulations vary widely depending on the state. (Information on key issues is available in ASHA’s Medicaid Toolkit.)
Private health plans—such as Aetna or UnitedHealthCare—cover beneficiaries through employer-based health plans or individual policies purchased through state health insurance exchanges. Coverage and policies vary significantly by plan, and some impose limits on audiology and speech-language pathology services. ASHA has more information on working with private health plans.
Each payer has separate guidelines on coverage, enrollment, eligible providers and billing. Some rules also vary by setting. It is up to you to get to know the payer. Review contracts, fee schedules, policy manuals and medical coverage guidelines. Most important, know who to contact or where to go online to find information, and don’t be afraid to ask questions.

Your name goes on the signature line as the rendering provider, so it’s important for you to be confident that you have provided and documented your services appropriately.

How can I make sure my services are paid for?
There is no guarantee that insurers will reimburse for services. Even initial payment of a claim does not necessarily mean that the service is covered or will continue to be paid. However, there are some key considerations that can determine the success of your claims, especially upon audit:
  • Get your NPI number. Most payers require providers to obtain a national provider identifier (NPI) number. Think of it like a driver’s license. This number tells health plans who you are. It follows you, even when you switch jobs or settings. Getting an NPI number is fast, easy and free.

  • Know the players. It’s critical to know the payers and their coverage and reimbursement requirements.

  • Make sure you are a “qualified provider” and that you are properly enrolled. Payers have different definitions for “qualified provider.” For example, Medicare considers clinical fellows (CFs) to be qualified providers if they have a state-issued license, but some Medicaid programs do not. You also may be required to enroll with the payer to provide services. Medicare, for example, requires audiologists and speech-language pathologists to enroll as providers and prohibits them from entering into private-pay agreements with Medicare beneficiaries. But some Medicaid programs and private health plans allow private-pay arrangements.

  • Supervise or ensure that you are being supervised appropriately. Everyone is in a supervisory relationship—whether you supervise or are a student, aid, assistant, or CF without temporary licensure—and you need to follow the supervision guidelines for each payer, which can vary greatly. For example, Medicare requires 100-percent, in-the-room supervision of students for outpatient services, and considers unlicensed CFs as students.

  • Be aware of referral and preauthorization requirements. Some payers or settings may require a physician referral or order to provide treatment. Medicare does not require a referral or order, but requires a physician to be involved in the care of the patient and to sign off on the plan of care. Additionally, many Medicaid programs and private health insurance plans require clinicians to submit an evaluation report and preauthorization request before you begin providing services.

  • Establish medical necessity. Services must be medically necessary—or reasonable and necessary—but these definitions are often vague and will be determined by the payer. Check with payers for their definitions!

  • Understand documentation requirements. Documentation requirements vary by setting and payer, but Medicare guidelines—requiring an evaluation, plan of care, treatment notes, progress reports and discharge note—may serve as a minimum standard. Remember, if you didn’t document it, it didn’t happen! ASHA’s Practice Portal includes information on documentation for audiology and speech-language pathology.

  • Provide and describe only skilled services. Your services should be skilled—meaning they require the expert knowledge and clinical decision-making of an audiologist or SLP. If someone other than an audiologist or SLP can perform the services, they may be considered unskilled and not payable. In your documentation, use terms that demonstrate your skilled services.

  • Know the codes. Billing codes communicate to payers the client’s diagnosis and the services or devices you provided. Documentation and information in the medical record must support the reported codes.

Clinicians should never choose codes based on their likelihood of being paid.

How do I know if I’m choosing the correct billing codes?
There are two main health care coding systems.
  • The International Classification of Diseases (ICD-10) describes the reason you are evaluating or treating the client/patient.

  • The Health Care Common Procedures Coding System (HCPCS) is split into two parts. Level I Current Procedural Terminology (CPT) codes represent what you do with the client/patient (procedures and services). HCPCS Level II (“hik-piks”) codes are used to report supplies, equipment and devices.

  • You need an ICD-10 diagnosis code and a CPT procedure code (and HCPCS Level II code, if applicable) when you file claims.

The underlying principle for appropriate coding is to choose the codes that best describe the client/patient’s condition and the services provided. The medical record and your documentation must support your choices.
Be aware of what codes each payer will accept. For example, Medicare’s fee schedule includes payable CPT codes, and its coverage determinations outline what ICD-10 codes are accepted as medically necessary. It is important to note that clinicians should never choose codes based on their likelihood of being paid. Additionally, a successfully processed and paid claim does not necessarily mean the codes were appropriate for the services provided, which could be revealed if you are ever audited. Make sure you are following payer and coding guidelines.
Find extensive coding resources for audiologists and SLPs, including ICD-10 and CPT code lists and guidance on various coding issues.
How can I possibly keep up with all of these requirements? Where do I go for more information?
Payer requirements can be overwhelming, especially when they vary so much, but you will become more comfortable as you gain knowledge and experience through daily work. The key is to know your payers, know who to contact and be willing to ask questions.
ASHA also has many resources, and ASHA staff can help with specific questions. Email reimbursement@asha.org for payer policy, reimbursement, billing and coding questions.
To stay current on Medicare and other policy changes, sign up for ASHA Headlines and follow ASHA Advocacy on Facebook and Twitter to receive ongoing updates related to coding and reimbursement.
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FROM THIS ISSUE
October 2017
Volume 22, Issue 10