What’s New for School-Based SLPs Who Bill Medicaid? SLPs may want to add a Medicaid refresher to their list of to-dos for the new school year. Bottom Line
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Bottom Line  |   August 01, 2018
What’s New for School-Based SLPs Who Bill Medicaid?
Author Notes
  • Laurie Alban Havens, MA, CCC-SLP, is ASHA’s director of Medicaid and private health plan policy. lalbanhavens@asha.org
    Laurie Alban Havens, MA, CCC-SLP, is ASHA’s director of Medicaid and private health plan policy. lalbanhavens@asha.org×
Article Information
School-Based Settings / Practice Management / Professional Issues & Training / Bottom Line
Bottom Line   |   August 01, 2018
What’s New for School-Based SLPs Who Bill Medicaid?
The ASHA Leader, August 2018, Vol. 23, 32-33. doi:10.1044/leader.BML.23082018.32
The ASHA Leader, August 2018, Vol. 23, 32-33. doi:10.1044/leader.BML.23082018.32
As students and school staff scramble to get ready for the new academic year, providers who bill services to Medicaid may want to brush up on how and when to submit claims for Medicaid-eligible students.
The information here generally applies to all Medicaid plans. The federal government establishes national Medicaid guidelines, but each state administers its own plan and has its own eligibility standards, coverage determinations and payment schedule. School-based providers should always check with their state’s Medicaid program for specific guidance.
Codes, codes, codes
Audiologists and speech-language pathologists in schools should be aware of codes used in billing services. Briefly, there are three types of codes.
Procedure codes. The Current Procedural Terminology (CPT,   American Medical Association) code set is used to describe procedures and services. As of Jan. 1, 2018, a new CPT code designates cognitive treatment. The 97127 code (untimed) replaces the 97532 (timed) code.
97127 is described as direct, one-on-one therapeutic interventions that focus on cognitive function (attention, memory, reasoning, executive function, problem-solving and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (managing time or schedules, initiative, organizing, and sequencing tasks). Not all payers allow SLPs to bill this code and some payers—including Medicaid in some states—use G0515, a code that maintains the timed nature of the procedure.
Modifiers. A two-character (letters and/or digits) modifier added to CPT codes designates specific clarification to the procedure. Some Medicaid plans may require the −96 modifier for children’s habilitative services, to distinguish them from rehabilitative services. In addition, in states that allow telepractice, the modifier GT or −95 may be required to indicate that services are provided remotely.
Condition codes. A student’s medical condition is described by ICD-10 codes (International Classification of Diseases, 10th revision). There are new codes and edits to describe the codes every year.
For example, this year, the edit “picky eater” was added to the description of the R63.3 (feeding difficulties) code.
Billing software/documentation
Although schools have been allowed to bill Medicaid for speech-language (and other) services for nearly 30 years, many districts choose not to, mostly because they have low Medicaid enrollment or because Medicaid billing processes can be challenging. Many districts, however, choose to submit Medicaid paperwork, especially with new software that eases the process.
Many school districts require providers to complete the Medicaid-compliant paperwork for all students on their caseload, not just those eligible for Medicaid. Administrators cite two reasons for this system. Students’ eligibility changes during the year, and eligibility may be retroactive—so completing documentation at the time of service eliminates the need to reconstruct it later. In addition, completing the documentation for all students allows providers to be blind to any given student’s Medicaid status.
The billing software and the person responsible for submitting Medicaid claims must ensure that only the services of those students who meet eligibility criteria are actually submitted. Providers are responsible for accurately documenting services in accordance with the plan of care, and administrative offices are responsible for accurately submitting the data.
Referral
Providers may bill Medicaid only for medically necessary services. In many states, the IEP team’s referral/approval for treatment establishes medical necessity. In other states, however, a physician (or other specified health care professional) must refer the student for school-based treatment. States may be tightening their medical necessity rules—in the past couple of years, for example, both Ohio and Illinois implemented more stringent referral requirements for school-based services.

In some states, a physician (or other specified health care professional) must refer the student for school-based treatment.

Managed care
A growing number of Medicaid beneficiaries are opting for managed care plans. These plans often require more documentation and paperwork, including additional documentation to demonstrate medical necessity, pre-authorization requirements, re-authorization requirements after a limited number of sessions, and frequent data submission.
Supervision/qualified providers
Some states allow SLPs to work in schools with a teaching license or certification, rather than a speech-language pathology license or certification. These SLPs cannot bill Medicaid, and the situation raises the question of whether these SLPs can provide services “under the direction of” and billing number of credentialed SLPs. If you are an SLP who supervises others who use your billing number, your level of supervision should ensure that you are knowledgeable about the students’ diagnoses and treatment plans. This situation also applies to clinical fellows in states that issue provisional licenses to clinical fellows but require the supervisor to bill for the service.
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FROM THIS ISSUE
August 2018
Volume 23, Issue 8