Billing and Reimbursement Frequently Asked Questions

ISHA's Billing and Reimbursement Committee has provided answers to some of the frequently asked questions regarding billing and reimbursement; this was updated on August 29, 2022.

Question: Can potential clients with Medicaid and/or Medicare pay for services out of pocket?

Answer: This question comes up frequently. In order to address it in the best way we need to break it down into parts:

A provider contracted with Medicaid:

Providers willing to accept Medicaid cannot charge the recipient for Medicaid services and agree to accept Medicaid reimbursement as payment in full. Some KidCare programs, however, require recipients to pay various co-payments, the amount of which depends on the program under which they are covered. A provider may not refuse treatment to a person who has not paid their co-payment.

Providers who have agreed to accept Medicaid payment for service may not seek payment from the recipient if Medicaid payment is not made due to the provider’s failure to follow the procedures required in order for the provider to obtain Medicaid reimbursement. A provider has accepted Medicaid payment if:

   •   The provider makes an affirmative representation to the recipient that payment for services will be sought from Medicaid; 
   •   The recipient presents the provider with his or her Medicaid card and the provider does not indicate that other payment arrangements will be necessary; and 
   •   The provider submits a bill for the covered services to HFS. 
89 Ill. Admin Code 140.
Illinois Department of Healthcare and Family Services (HFS)

A provider NOT contracted with Medicaid:

It is our ethical responsibility to inform potential clients that we are not contracted providers with Medicaid and to provide them resources to find contracted providers.

An enrolled Medicare provider:

Summary: If the patient has Medicare, providers cannot charge the patient but must bill Medicare if the service is a covered service. Details below.

The Social Security Act (Section 1848(g)(4)) requires that claims be submitted for all Medicare patients for services rendered on or after September 1, 1990. This requirement applies to all physicians and suppliers who provide covered services to Medicare beneficiaries, and the requirement to submit Medicare claims does not mean physicians or suppliers must accept assignment. Compliance to mandatory claim filing requirements is monitored by CMS, and violations of the requirement may be subject to a civil monetary penalty of up to $2,000 for each violation, a 10 percent reduction of a physician’s/supplier’s payment once the physician/supplier is eventually brought back into compliance, and/or Medicare program exclusion. Medicare beneficiaries may not be charged for preparing or filing a Medicare claim.

For the official requirements, see the following:
• Social Security Act (Section 1848(g)(4)(A); “Physician Submission of Claims”)
• Requirement to file claims – The Medicare Claims Processing Manual, Chapter 1, Section 70.8.8

Exceptions to Mandatory Filing

Physicians and suppliers are not required to file claims on behalf of Medicare beneficiaries for:

Used Durable Medical Equipment (DME) purchased from a private source;
Medicare Secondary Payer (MSP) claims when you do not possess all the information necessary to file a claim; 
Foreign claims (except in certain limited situations) MLN Matters® Number: SE0908 Related Change Request Number: N/A 
Services furnished by opt out physicians or practitioners (except in emergency or urgent care situations when the opt out physician or practitioner has not previously entered into a private contract with the beneficiary); 
Services that are furnished for free; or 
Services paid under the indirect payment procedure.

For further details, see the Medicare Claims Processing Manual (Chapter 1, Section 70.8.8.8) on the CMS website.

Note: You are not required to file a claim for a service that is categorically excluded from coverage (e.g., cosmetic surgery, personal comfort services, etc; see 42 CFR 411.15 for details). However, many Medicare supplemental insurance policies pay for services that Medicare does not allow, and they may require a Medicare denial notice.

Question: What are the best ways to use the new cognitive codes?

“I have a question regarding CPT code 96125 (standardized cognitive performance test) if you have any resources so I can better understand how this works in terms of the billing process for Medicare payor sources.”

Answer: According to the Center for Medicare and Medicaid Services (CMS) and ASHA, the CPT code 96125, Standardized Cognitive Performance Testing, is a Per Hour code which has specific parameters outlined by CMS.

96125 is defined by CMS as standard cognitive performance testing (eg., Ross Information Processing Assessment) per hour of a qualified health care professional’s time, both face-to-face with the patient and time interpreting test results and preparing the report.

Minimum Data Set (MDS) minutes are recorded for the time the SLP is with the patient performing the assessment. The SLP logs the time away from the patient when interpreting the test results, completing the test booklet, etc. as Non-MDS minutes. The total minutes captured equal one unit if 31-90 minutes. Most situations are not going to require 91 or more minutes to bill the code again.

According to the American Medical Association, “A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and 60 minutes). A second hour is attained when a total of 91 minutes have elapsed.” When the patient requires less than 31 minutes of the therapist’s time, the minimum requirements have not been met for billing 96125. When the patient requires between 60 - 90 minutes of the therapist’s time, this is still reflective of one unit billed toward 96125.

Question: “Now what about the cognitive codes for treatment? What is the best practice use of 97129 and 97130 for treating cognition?”

Answer: 97129 include therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-to-one) patient contact, initial 15 minutes; and 97130 include therapeutic interventions that focus on cognitive function… for each additional 15 minutes and listed separately in addition to the code for the primary procedure.

Reimbursement / Coverage Considerations

Therapists are responsible for understanding coverage criteria for the patient’s payer source. Coverage determinations vary significantly regarding the use of Cognitive Interventions (97129/97130).  
Certain Medicare, Managed Care, and Commercial Insurances will only cover 97129/97130 for acquired cognitive impairments such as: head trauma and acute neurological events.  
Services must be reasonable and necessary to improve, restore, maintain or prevent further deterioration of cognitive skills (e.g. attention, memory, problem solving).

Best practice tips:

Pay careful attention to each code descriptor 
Include both codes in your patient’s plan of care 
Codes must be used in the order described in the code descriptor 
Ensure your commercial insurer accepts the codes prior to usage 
Ensure you and/or your team understand the use of 92507 versus 97129/97130: 97129 and 97130 should not be billed on the same day as CPT code 92507 (speech, language, voice, communication treatment)  
Communication by therapy practitioners is crucial when sharing a service on a given day (i.e. cognitive-linguistics via SLP and cognitive function via OT)

Question: What are CAPD/Language exclusions (audiology)?

Answer: For testing for Central Auditory Processing , 92620 covers the first 60 mins (evaluation, report). For each additional 15 minutes of testing, the code 92621 is utilized.

Treatment falls under 92507 and there are no exclusions. However, CMS does not recognize audiologists as providers, only suppliers. So, audiologists are not able to bill for treatment services through Medicare. Unfortunately, this also varies with insurance companies.

Question: What is the difference between a script vs. referral?

Answer: The ISHA website provides guidance for members about the difference between a script and a referral Medicaid Referral Requirement. Colleagues from other disciplines who provide skilled services may be required to obtain a written prescription that orders evaluation and/or treatment from a very limited set of practitioners. A speech-language pathologist operates under different requirements that are context-specific.

A speech-language pathologist in a school setting who plans to bill Medicaid for any skilled services must obtain a written referral from a physician or other licensed practitioner of the healing arts acting within the scope of his or her practice under state law. The written referral should cite a recommendation for evaluation/treatment of speech and language needs;however,the professional providing the care will determine the exact nature of the service needed. These practitioners include, but are not limited to, physician assistants, advanced practice nurses, clinical psychologists, and/or another speech-language pathologist. 225 ILCS 47/ Health Care Worker Self-Referral Act. Similarly, referral from a limited set of provider types is needed for a speech-language pathologist who conducts laryngeal examination with a rigid or flexible endoscope 225 ILCS 110/ Illinois Speech-Language Pathology and Audiology Practice Act. The difference between an order, referral, and certification is a service consideration for Medicare beneficiaries. The 2020 Medicare Benefit Policy Manual, Chapter 15, published by the Centers for Medicare and Medicaid Services, states that a physician’s order is not required, though might be prudent, for outpatient therapy services (pg. 153).

Question: Where can I find information on EI Billing?

Answer: The best place to start is with the Early Intervention Central Billing Office (EI CBO)
Additionally, these Early Intervention partner programs have good information:

Question: What are some reasons that claims would be denied?

Answer: Below is a list of some reasons claims have been denied (this is not an exhaustive list):

Prior authorization was not obtained 
ST for the client's diagnosis is an exclusion on the plan (e.g. codes considered to be “developmental” are not covered) 
Place of Service is not covered (e.g. teletherapy) 
Plan visit limit has been reached for plan year 
Service is not deemed medically necessary  
Provider is out of network (some plans have out of network benefits, but not all) 
Correct modifier was not provided on the claim (depending on the plan, some require a GN modifier and if more than one service is provided within a day, modifier 59 may be needed)

Question: Can dyslexia be reimbursed?

Answer: Please note that dyslexia services are often considered education instead of a medical necessity. Because of this, most dyslexia assessments and therapies are private pay.

Question: Can you negotiate your rates with private payers?

Answer: Usually. Each private payer has different rules for setting fee schedules. However, you often can negotiate your contracted rate, especially if you have a limited number of providers in the area that are contracted with that specific payer.

Question: How do you go about negotiating your rates with private payers?

Answer: Each payer handles things a little differently. The first step is to contact the health plan provider relations representative or contracting department. Most health plans will want you to send in a letter explaining your request. It is important to remember the following to include in your letter or discussion:

Target specific codes for increases
State your argument for why you/your practice should be compensated at a higher rate.
Some ideas for things that may apply to your situation:

Few providers in your area that are accepting the plan/accepting new patients
Length of time since last increase (maybe you have had the same rate for the last X number of years, despite inflation or other rates increasing over the same period of time)
Have documentation and facts in your letter to back up your request

Question: What can I do if speech/language services are being denied because an ABA therapist is also billing for the same patient?

Answer: ABA therapists are now licensed therapists in the state of Illinois. Here are some considerations:

Keep in mind the CCI edits For example: Code 92507 (individual treatment) may not be reimbursed if it is billed on the same day as the following ABA codes:

97153(Adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, every 15 minutes.
97154 (Group adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified healthcare professional, with two or more patients, every 15 minutes.
97155 (Adaptive behavior treatment with protocol modification, administered by a physician or other qualified healthcare professional, which may include simultaneous direction of a technician, face-to-face with one patient, every 15 minutes.
97156 (Family Adaptive Behavior Treatment Guidance, administered by QHP (with or without patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes
97157 (Multiple-family group adaptive behavior treatment guidance, administered by a physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, every 15 minutes.
and 97158 (Group adaptive behavior treatment with protocol modification, administered by a physician or other qualified healthcare professional, face-to-face with multiple patients, every 15 minutes.

Verify that you are not seeing the patient on the same day as an ABA therapist.
Verify that the ABA therapist is not using speech/language codes in their billing. Using speech/language codes in their insurance documentation is outside of their scope of practice.
Billing attests to the services provided.