You have accessThe ASHA LeaderBottom Line1 Jun 2014How Medicare Reimbursement Works in Skilled Nursing FacilitiesSLPs and other rehab professionals feel squeezed by a system that reimburses skilled nursing facilities only for face-to-face time with patients. Mark Kander Mark Kander Google Scholar More articles by this author https://doi.org/10.1044/leader.BML.19062014.26 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Many speech-language pathologists who work in skilled nursing facilities express concerns about “productivity”—that is, how much time their employers require them to provide face-to-face treatment with patients (see “Under Pressure”). Productivity requirements, which in some facilities may approach 100 percent, leave little time for SLPs to complete other tasks that are important to patient care. To understand the issue, it’s helpful to understand the Medicare rules for skilled nursing facility reimbursement. What is the basis for SNF reimbursement? SNFs are reimbursed by Medicare Part A (hospital or inpatient) or Medicare Part B (medical or outpatient), depending on the status of the patient. To qualify for a SNF stay under Part A, the Medicare beneficiary must have had a qualifying hospital inpatient stay of at least three days. Part A services are reimbursed under a prospective payment system that pays facilities a daily rate that covers all patient-related expenses, including nursing services, therapy services—calculated in minutes—and a daily room charge. The predetermined rate for each patient is based on the type and quantity of skilled services the patient will need. Depending on this mix of services, the patient is classified into a “resource utilization group”—or RUG—that determines the facility’s daily reimbursement for that patient. The more skilled services a patient needs, the higher the RUG, and the greater the reimbursement to the facility for inpatient services. In contrast, Medicare Part B pays for each therapy service provided, using Current Procedural Terminology (CPT, © American Medical Association) procedure codes. If the Part B patient is staying in the facility, charges for room, board and other services may be paid by the patient, Medicaid or other insurance. Even though Part A does not use CPT codes, many SNFs require therapists to document and use CPT codes for Part A patients as a means of internal accounting for treatment time. How does Medicare determine payment levels under Part A? Each Part A patient’s RUG is based on an overall assessment of the patient, which includes the amount of rehabilitation therapy minutes (occupational, physical and speech combined) the patient needs per week. The highest of the five rehabilitation RUG levels—“ultra high”—requires at least 720 therapy minutes per week, followed by “very high,” at least 500 minutes. These thresholds are minimum requirements, and Medicare rules clearly state that if the rehabilitation professional and attending physician agree that the patient needs additional minutes, the facility must arrange and pay for them. The facility, however, does not receive additional payment unless the increase in minutes bumps the patient to a higher RUG. According to Part A regulations, what clinician activities can be counted as part of therapy minutes and what cannot be included? Only face-to-face treatment time is included in therapy minutes, which are recorded in one-minute increments (not 15 or 30 minutes, as with some outpatient codes). Rules for co-treatment—that is, two clinicians from different disciplines treating one patient at the same time—allow both providers to count a portion of the session. Under group treatment—one clinician treating up to four patients who are performing the same or similar activities—each patient’s received minutes is equal to the total length of the session divided by four, regardless of the number of patients participating. This rule also applies to concurrent treatment, defined as one clinician treating two patients (regardless of payer source of the second resident) who are not performing the same or similar activities. Family education, with the patient present, can be counted in therapy minutes and must be documented in the record. Also, re-evaluations conducted as a part of the patient’s plan of care are counted in therapy minutes. Activities that cannot be counted as therapy minutes include initial evaluations, documentation and family education without the patient present. They are considered a part of the base rate for the inpatient stay. What distinguishes a SNF level of care from other long-term care facilities? SNFs require a three-day qualifying hospital stay and the patient’s need for skilled nursing and/or rehabilitation services at least five days a week. The need for skilled care must be related to the same diagnosis that triggered the hospital stay (or, if applicable, to an additional condition that developed in the SNF during a stay for the original hospital-related condition). Freestanding rehabilitation hospitals and certified rehab units in acute hospitals are for patients who require more intense care, usually a minimum of three hours of daily therapy and other medical needs. Do patients in skilled nursing facilities ever qualify for Part B (outpatient) services without an inpatient stay? If the patient does not have a qualifying hospital stay, or if the hospital stay is subsequently denied, therapy services may be billed to Part B (outpatient) services if the patient has Part B coverage. Therapy services can also be covered under Part B if the patient has exhausted the Part A benefit (100 days per episode of illness) or if skilled nursing and/or rehabilitation services are no longer needed at least five days per week. In these situations, the daily room and board is paid by the patient, Medicaid or another third party; Medicare B reimburses only for therapy services. Some SNFs offer outpatient services to non-residents, which would always be considered Part B. Are the Part B therapy rules in a SNF the same as for other Medicare outpatients? The rules that govern coverage, documentation and payment requirements for these patients are the same as for other Part B patients, including functional outcome reporting requirements with G-codes and Medicare Part B documentation requirements. Under what circumstances may SLPs or audiologists bill Medicare directly for services provided to SNF patients? SLPs may never bill Medicare directly for SNF patient services, regardless of whether the patient is covered by Part A or Part B. The facility—or the company contracted to provide rehabilitation services to the facility’s patients—pays the SLPs. Audiologists may bill Medicare directly for services provided to Part B patients in SNFs. The facility pays audiologists for services provided to Part A patients. Does Medicare issue guidelines for payment levels of health care professionals in skilled nursing facilities? Medicare does not issue guidelines for the payment of SNF employees or contractors. Payment to a facility’s nursing and rehabilitation staff is fully negotiable. Does Medicare have guidelines related to productivity—that is, the number of reimbursable minutes a clinician is expected to provide relative to the total amount of time the practitioner spends “on the clock”? Medicare establishes no such guidelines. Productivity requirements are established by individual facilities or the rehabilitation companies with whom they contract to provide services. Where can I get more information about the Medicare SNF rules? ASHA has the Medicare rules for SNFs, with the resources, available at on.asha.org/medicare-snf. Author Notes Mark Kander is ASHA director of health care regulatory analysis. [email protected] Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 19Issue 6June 2014 Get Permissions Add to your Mendeley library History Published in print: Jun 1, 2014 Metrics Current downloads: 12,256 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2014 American Speech-Language-Hearing AssociationLoading ...

You have accessThe ASHA LeaderPolicy Analysis1 Jan 2014Policy Analysis: Medicare Alters Outpatient Hospital Audiology Rates for 2014 Mark Kander Mark Kander Google Scholar More articles by this author https://doi.org/10.1044/leader.PA2.19012014.np SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Medicare Alters Outpatient Hospital Audiology Rates for 2014 By Mark Kander Medicare reimbursement rates for several audiology hospital outpatient billing codes have increased substantially in 2014, according to the 2014 final rule for the hospital outpatient prospective payment system issued in late November 2013 (see chart below). Reimbursement levels for several individual vestibular tests increase by 13 percent; however, the rate for basic vestibular evaluation, CPT 92540 (Common Procedural Terminology,® American Medical Association), increases 4.8 percent. The fee for CPT92586, screening using auditory evoked potentials, increases 60 percent to $128, significantly surpassing the Medicare non-hospital rate and serving as a valuable fee reference used by other payers. The comprehensive hearing test (CPT 92557) incurs a rare decrease of 15.4 percent, but the rate remains more than twice as high as the Medicare non-hospital fee. The payment rate for cochlear implantation (including the device) increases by 1.4 percent, and the rate for osseointegrated implantation (with device) increases by 1.3 percent. Hospitals report that although the cochlear device cost is covered in this rate, the complete surgical costs are not. The hospital outpatient prospective payment system determines rates by assigning CPT codes to ambulatory payment classifications. The codes in any given classification are comparable clinically and with respect to resource use, based substantially on national hospital cost records from two years prior. The 2014 rule changes the classification of several audiology-related procedures, resulting in substantial reimbursement increases or decreases for some of the re-assigned codes. The final rule for hospital outpatient services also consolidates some hospital outpatient physician office visits from 10 procedure codes to one—and a single payment level. The American Hospital Association has been critical of this decision, stating that this will result in payment levels well below the cost of treating complex patients. Although this regulation does not affect audiologists directly, ASHA is carefully watching this trend. Codes with an increase of at least 10 percent Codes with an increase of at least 10 percent Codes with an increase of at least 10 percent Codes with a decrease of at least 10 percent Codes with a decrease of at least 10 percent Author Notes Mark Kander is ASHA director of health care regulatory analysis. [email protected] Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 19Issue 1January 2014 Get Permissions Add to your Mendeley library History Published in print: Jan 1, 2014 Metrics Current downloads: 61 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2014 American Speech-Language-Hearing AssociationLoading ...

A new Medicare proposal that would change speech-generating devices from purchase-only equipment to rent-to-own equipment could be better for the patients who use them.

You have accessThe ASHA LeaderBottom Line1 May 2014Changes Ahead for Speech-Generating Device ReimbursementSGDs—as part of a Medicare category that includes high-ticket equipment and are, therefore, often the target of fraud and abuse—face tighter restrictions. Mark Kander, and Lisa SatterfieldMS, CCC-A Mark Kander Google Scholar More articles by this author and Lisa Satterfield Google Scholar More articles by this author , MS, CCC-A https://doi.org/10.1044/leader.BML.19052014.26 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In As the Centers for Medicare and Medicaid Services tightens policies on Part B (outpatient) durable medical equipment, augmentative and alternative communication devices get swept up in changes designed more for power wheelchairs and diabetes supplies. Speech-generating devices, a type of AAC device, have been covered by Medicare since 2001. Medicare classifies SGDs as durable medical equipment because they can withstand repeated use, are medical devices used for injury or a condition, and are appropriate for home use. Widespread fraud and abuse involving other items in the category, including mobility equipment and medical supplies, have triggered legislation and regulations to restrict who can get DMEs and the processes to obtain the often high-priced equipment. Is there a new requirement that a patient has to visit a physician to get an SGD? Yes, but the rule has yet to take effect. Under a provision of the Affordable Care Act, certain items—including SGDs—require documentation of a face-to-face visit with the ordering physician. This new rule does not change the longstanding requirement for an evaluation by a speech-language pathologist, but it does require the manufacturer or supplier to ensure that the user has, in fact, had a face-to-face visit with the physician within six months prior to obtaining the device. Previous regulations required only that the ordering physician have a written evaluation signed by a certified SLP. This new provision, originally set for implementation on July 1, 2013, has been delayed several times; a new implementation date is expected sometime this year. Does the beneficiary own or rent the device? SGDs made the short list of items now available to Medicare beneficiaries only as rent-to-own—that is, Medicare pays the supplier a monthly fee for 13 months, after which the beneficiary owns the device. The policy is harmful and dangerous to patients who require inpatient care during the rental period, as ASHA indicated to CMS in response to the proposed change, which went into effect April 1. If a beneficiary requires inpatient care during the rental period, Medicare does not allow payment to the supplier during the hospitalization, when Part A covers patient costs. Because the Part B payments to the supplier stop, the supplier would then have to request the device be returned. Many SGD users have chronic, progressive conditions that require inpatient stays. Without their SGDs, these patients cannot communicate with nurses, physicians and other inpatient caregivers, compromising their safety and health. Representatives of ASHA and a patient advocacy group recently met with with top-level CMS administrators to request that all SGDs be exempt from the capped rental policy. Immediate changes are not anticipated, but ASHA will continue to press CMS on this issue. Will Medicare pay for tablets that, with appropriate apps, can be used as SGDs? Medicare does not cover a tablet because it is not a dedicated medical device (that is, used only as an SGD). ASHA has also addressed this issue with high-level CMS officials, who reiterated that Medicare will pay only for dedicated devices. They indicated that if less-expensive tablets and software are, indeed, viable options that could replace dedicated SGDs, there would be no reason to continue covering the dedicated devices. ASHA recognizes that some patients’ functional impairments require the technology and durability of the dedicated SGD, and will continue to advocate for access to the most efficient, clinically appropriate device that meets the beneficiary’s medical needs. However, Medicare may cover tablet software or apps, if they can be obtained through a CMS-approved supplier. Medicare will not cover apps or software the user purchases independently. Medicare and some Medicaid and private health plans recognize a software billing code under the Healthcare Common Procedure Coding System, which establishes DME billing codes: E2511, “Speech-generating software program, for personal computer or personal digital assistant.” Medicare coverage for SGDs and software is identical nationwide: Generally, SGDs can be purchased only once every five years. This rule, however, is not clear for app purchases, and ASHA is seeking clarification from CMS. Regardless of the timing, however, the reimbursement must be to the CMS-approved supplier. The supplier, therefore, must document the delivery—with the tablet as the end user—because the app provider must be able to deliver updates and fixes. How do I code SGD evaluation and treatment? Medicare recognizes three Common Procedural Terminology (CPT © American Medical Association) codes for evaluation (92607 and 92608) and treatment (92609) for SGDs. It is not appropriate to use 92597 (evaluation for voice prosthesis) when billing for an SGD. Medicare does not, however, include codes for non-speech generating devices (92605, evaluation, and 92606, treatment) in its fee schedule and does not reimburse separately for them. In deciding to exclude the non-SGD codes from Medicare, CMS indicated that SLPs could perform non-SGD activities as part of broader evaluation and treatment. However, with four new specific evaluation codes replacing the general evaluation code (92505) in 2014, ASHA asked CMS to allow SLPs to use the non-SGD codes for separate reimbursement. Until the issue is resolved, SLPs should not bill separately for the non-SGD services. What role does the federal government play in regulating SGDs? No government entity carefully reviews the efficacy of traditional SGDs. The Food and Drug Administration reviews the user guides for new medical devices and equipment but focuses primarily on determining that the device is not harmful. The rationale for minimal review of non-life threatening devices is that health care consumers will stop purchasing devices that don’t work well. In published guidance, the FDA explains that oversight of medical apps applies only to those that present a greater risk to patients if they don’t work as intended. The FDA encourages app developers to contact the agency with questions about the app’s level of risk and need for a premarket application. Licensed practitioners who create apps solely for use in their professional practice are not subject to FDA oversight. For further information, contact [email protected]. Author Notes Mark Kander, is ASHA director of health care regulatory analysis. ■[email protected] Lisa Satterfield, MS, CCC-A, is ASHA director of health care regulatory advocacy. ■[email protected] Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 19Issue 5May 2014 Get Permissions Add to your Mendeley library History Published in print: May 1, 2014 Metrics Current downloads: 237 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2014 American Speech-Language-Hearing AssociationLoading ...

If you’re thinking about using speech-generating apps for mobile devices in treatment, know that getting insurers to pay for them can be tricky.

A recent settlement eliminates the need for "functional progress" and allows patients with progressive conditions to receive maintenance services.

SLPs' responsibilities don't change under the new rule, which is designed to reduce fraud, waste and abuse.

Per-episode payments would decrease under the proposed rates, but per-visit rates for SLPs would rise by 6 percent.

You have accessThe ASHA LeaderBottom Line1 Jul 2012New Cognitive Code Use Is Inconsistent Janet McCarty, andMEd, CCC-SLP Mark Kander Janet McCarty Google Scholar More articles by this author , MEd, CCC-SLP and Mark Kander Google Scholar More articles by this author https://doi.org/10.1044/leader.BML1.17082012.1 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In New diagnosis codes for cognitive communication deficits have been available for almost two years, but not all health plans—including Medicare—recognize them or allow speech-language pathologists providing cognitive rehabilitation services to use them. The new codes, which became effective Oct. 1, 2010, were introduced into the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) in response to efforts by the U.S. Departments of Defense and Veterans Affairs to improve the coding of intracranial injuries and associated symptoms. The new ICD-9-CM diagnostic subcategory [PDF] for signs and symptoms involving cognition (799.5x) captures a spectrum of cognitive disorders. Private and federal health plans are inconsistently incorporating the 799-series codes. Most Medicare administrative contractors (MACs) recognize at least one of the codes (see chart [PDF]). The Medicare scope of coverage for speech-language pathology includes cognitive rehabilitation treatment, but the regional MACs independently specify covered diagnosis and procedure codes in their local coverage determinations. In communication with all MACs, ASHA requested that they include 799.52 (cognitive communication deficit) in their local coverage determinations, and continues to advocate for their use. TRICARE, the health insurance program for service members and their families, does not cover cognitive rehabilitation—although individual speech-language services are covered. An Institute of Medicine study on cognitive rehabilitation—commissioned by the U.S. Department of Defense, which is looking for ways to deal with the rising incidence of TBI among service members returning from the conflicts in Iraq and Afghanistan—was deemed not sufficiently conclusive (The ASHA Leader, Dec. 20, 2011). SLPs can use diagnosis code 784.69 (other symbolic dysfunction) to capture neurological language impairments, including cognitive communication problems, if the patient’s MAC is not using the 799-series codes (every MAC includes 784.69 in its speech-language pathology scope of coverage). If the MAC also allows 799.52, SLPs should use only one code to describe cognitive communication deficits (one or the other, but not both). If the cognitive disorder is caused by a stroke, use 438.0 (cognitive deficits: late effects of cerebrovascular disease). One MAC (Novitas) specifies that an additional code, besides 438.0, should be included “to clarify the reason/diagnosis for SLP services.” Clarification Although the 799 codes were developed specifically to focus on TBI and associated symptoms, the codes might be used for a range of disorders. To clarify their appropriate use, ASHA is working with the ICD-9-CM Coordination and Maintenance Committee of the National Center for Health Statistics to provide guidance on how speech-language pathologists may use them. The committee is working with the American Hospital Association (AHA)—the U.S. clearinghouse for issues related to the use of ICD-9 codes—which is expected to publish guidance in the AHA Coding Clinic shortly. The Value of Cognitive Rehabilitation Medicare recognizes the role of speech-language pathologists in providing cognitive rehabilitation in the Center for Medicare and Medicaid Services Program Memorandum AB-00-14 (March 2000). Additionally, outcomes data, systematic literature reviews, and research all point to the efficacy of cognitive rehabilitation. However, Medicare requires that rehabilitative services result in significant functional progress in a reasonable period of time—that is, the patient functions with a higher level of independence after two to four weeks of treatment. Data from ASHA’s National Outcomes Measurement System show that most patients with TBI who received speech-language pathology services made at least one level of progress on the functional communication measures in four key areas of cognitive-communication skills: attention, memory, pragmatics, and problem-solving. Patients with cerebrovascular disease (right-hemisphere) who received speech-language treatment also improved in attention, memory, pragmatics, and problem-solving. An Archives of Physical Medicine and Rehabilitation article, “Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002” (August 2005), reports that there is “substantial evidence to support cognitive-linguistic therapies for people with language deficits after left hemisphere strokes,” as well as for people with TBI. Author Notes Janet McCarty, MEd, CCC-SLP, private health plans advisor, canbe reached at [email protected]. Mark Kander, private health plans advisor, canbe reached at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 17 Issue 8 July 2012 Get Permissions Add to your Mendeley library History Published in print: Jul 1, 2012 Metrics Current downloads: 369 Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2012 American Speech-Language-Hearing AssociationLoading ...

You have accessThe ASHA LeaderBottom Line1 Aug 2012Medicare Manual Review Rules to Affect Providers Lisa Satterfield, andMS, CCC-A Mark Kander Lisa Satterfield Google Scholar More articles by this author , MS, CCC-A and Mark Kander Google Scholar More articles by this author https://doi.org/10.1044/leader.BML1.17102012.4 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Claims for all Medicare outpatient therapy services that exceed $3,700 for a single beneficiary—with no exceptions for any diagnoses—will be subject to medical review, according to newly released guidelines. Providers must request pre-approval to ensure reimbursement. The Middle Class Tax Relief and Job Creation Act mandates the Centers for Medicare and Medicaid Services (CMS) to conduct “manual medical review” of 2012 claims that exceed $3,700 (for combined speech-language treatment and physical therapy) on or after Oct. 1. Its language was similar to a 2006 rule that allowed exceptions for certain diagnoses, including aphasia and dysphagia (“Manual Medical Review: Are You Ready?”, The ASHA Leader, July 3). The new guidelines, however, do not include those exceptions. Under the three-phase process, providers will be categorized by facility type, then ranked by claims volume and number of high-utilization patients. The reviews for Phase 1 (providers who submit high volumes of Medicare Part B therapy claims and/or who have individual clients with high usage) begin Oct. 1; Phase 2 (mid-range providers) begins Nov. 1; Phase 3 (low-range providers) begins Dec. 1. Providers can request pre-approval for services above $3,700 in 20-treatment-day increments. Medicare Administrative Contractors (MACs) have 10 business days to respond. Requests that do not receive notification within 10 days are automatically approved. Claims submitted above the $3,700 without approval will be stopped and subject to standard medical review process (45 days for the provider to submit records, 60 days for the MAC to respond). The process timeline includes: Sept. 1—Providers receive their phase assignment by U.S. mail and at Centers for Medicare and Medicaid Services. Oct. 1—All therapy services submitted for payment since Jan. 1, 2012, are totaled in beneficiaries’ master files (available in the Health Insurance Transaction System and in the beneficiary eligibility file). Providers must ensure that therapy services beyond $1,880 include the –KX modifier. Phase 1 providers must request pre-approval for therapy services beyond $3,700. Nov. 1—Manual medical review for Phase 1 providers continues; Phase 2 providers must request pre-approval for therapy services beyond $3,700. Dec. 1—Manual medical review for Phase 1 and 2 providers continues; Phase 3 providers must request pre-approval for therapy services beyond $3,700. Dec. 31—Manual medical review and exceptions processes end, unless Congress acts to extend them. For more information, view the Therapy Cap Fact Sheet [PDF] and the Manual Medical Review Process [PDF] or e-mail [email protected]. Any new information from CMS will be available at ASHA’s Therapy Cap Exceptions Overview. Author Notes Lisa Satterfield, MS, CCC-A, director of health care regulatory advocacy, can be reached at [email protected]. Mark Kander, director of health care regulatory analysis, can be reached at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 17Issue 10August 2012 Get Permissions Add to your Mendeley library History Published in print: Aug 1, 2012 Metrics Current downloads: 48 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2012 American Speech-Language-Hearing AssociationLoading ...

You have accessThe ASHA LeaderBottom Line1 Aug 20122013 Medicare Proposal Outlines New Reporting Rules Lisa Satterfield, MS, CCC-A Neela Swanson and Kander Mark Lisa Satterfield Google Scholar More articles by this author , MS, CCC-A, Neela Swanson Google Scholar More articles by this author and Kander Mark Google Scholar More articles by this author https://doi.org/10.1044/leader.BML2.17102012.8 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Proposed 2013 reimbursement levels and associated rules for Medicare outpatient services will adjust reimbursement rates, affect therapy payment, and require participation in quality reporting in 2013. The Centers for Medicare and Medicaid Services (CMS) published the proposed 2013 Medicare Physician Fee Schedule and associated rules for Medicare Part B services in the July 30, 2012,Federal Register [PDF, 25.4 MB]. The rule is not final, however, and changes are expected. ASHA will express concerns with several aspects of the rule in comments to CMS. Therapy Caps and Reporting Requirements The proposed rule briefly recognizes two legislative mandates enacted in 2012—the manual medical review process for claims reaching $3,700 (speech-language pathology and physical therapy combined) and the inclusion on the claim form of the National Provider Identifier of the physician (or physician assistant, nurse practitioner, or clinical nurse specialist) who approves the therapy plan of care. Guidelines issued after the proposed fee schedule was released outline the manual medical review process (see “Medicare Manual Review Rules to Affect Providers”). Changes in therapy claims reporting were mandated by the Middle Class Tax Relief and Job Creation Act of 2012 in response to rising Medicare expenditures. CMS reports that 7.6 million Medicare beneficiaries received outpatient therapy services (speech-language treatment, physical therapy, and occupational therapy) in 2010. Expenditures for these services increased by 10.1% per year from 1998 to 2008; however, the number of Medicare beneficiaries receiving therapy services increased by only 2.9% per year in that same time. In an effort to limit medically unnecessary services, Congress in 1997 began “capping” the amount of outpatient therapy services each beneficiary could receive in a year; however, Congress also has passed an exceptions process that allows beneficiaries to receive services beyond those caps. The Act requires CMS to implement a claims-based data collection system for reforming the Medicare outpatient therapy payment system by Jan. 1, 2013. The proposed 2013 rule outlines a system for reporting patient outcomes that is based on a 12-point, 10-percentage-point incremental scale to measure functional limitations. Functional outcomes would be reported on the claim form, along with the Common Procedural Terminology (CPT, © American Medical Association) code for the service provided, using a series of G-codes with modifiers for up to two functional goals. The measures would be reported at the outset of therapy, at the earlier of the 10th treatment day or 30th calendar day, and at discharge. The proposed timing of the functional progress coding coincides with the current reporting timeline, which requires documentation at the start of care, at progress note intervals, and at discharge. Implementation is scheduled for Jan. 1, 2013, with a “testing period” from Jan. 1 to July 1. Required reporting would begin on July 1, 2013 (claims without the appropriate G-codes and modifiers would be returned unpaid). Reporting of the –GN modifier for all speech-language pathology services will continue, as will the –KX modifier for claims over the therapy cap amount (assuming Congress extends the exceptions process into 2013). In its comments on the proposed rule, ASHA will address several concerns with the functional reporting system: The system, including the 12-point severity scale, has not been subject to reliability or validity studies. The administrative burden for providers to implement a complex system is excessive. No standards exist to determine which claims will be rejected as inappropriate. The resulting subjective data will likely not provide valid information needed to develop a new payment model. There is a short time frame for implementation and education. ASHA also will advocate in comments that speech-language pathology functional outcomes be reported through NOMS instead of the system proposed by CMS. Proposed Fee Changes Changes in reimbursement rates are based on a mandated formula and variations in the values of individual CPT codes. Conversion Factor To calculate reimbursement rates, CMS uses a conversion factor that is based on a statutory formula (the Sustainable Growth Rate). Using that formula, the projected 2013 conversion factor is $24.8441, which is 27% less than the current $34.0376. However, Congress will most likely again enact legislation to prevent this reduction, as it has every year since 2003. Practice Expense The value of each CPT code is calculated by separating the cost of providing the service into relative value units (RVUs) in three components—professional work, technical expenses (practice expense), and professional liability insurance (malpractice). The total RVUs for each service is the sum of the three components (components are adjusted for geographical differences); the RVUs for any particular CPT code are multiplied by the conversion factor to determine the corresponding fee. In 2013, audiologists and SLPs will experience the final year of a four-year phase-in of practice expense value changes, the result of updated practice cost surveys. These surveys reflect data on average practice expenses and mostly affect indirect practice costs (such as office overhead, billing, rent, and utilities). These changes have decreased rates for many audiology and speech-language pathology procedures, mostly because the costs of operating an audiology or speech-language pathology practice are substantially less than those of a medical practice. If analysis of these changes reveals concerns about specific codes, ASHA will include these concerns in its comments. Multiple Procedure Payment Reduction Under the Multiple Procedure Payment Reduction (MPPR) policy, Medicare reduces payment for the second and subsequent therapy, surgical, nuclear medicine, and advanced imaging procedures furnished to the same patient on the same day. Audiology. No audiology procedures are affected by MPPR. In the 2012 proposed rule, however, CMS asked for comments on possible expansion of the policy to other procedures, including all diagnostic tests. This approach would apply a payment reduction to the technical component of the second and subsequent diagnostic tests provided in the same encounter. In comments, ASHA noted that there is no evidence that audiology diagnostic procedures performed on the same day are overvalued, and provided information on bundled audiology procedures that already include multiple procedure reductions. The 2013 proposed rule summarizes the 2012 MPPR expansion proposal, but does not propose changes for 2013. CMS indicates that any expansion of MPPR would be presented in future rulemaking and subject to public comment. Nevertheless, ASHA’s comments will reiterate its concerns about applying MPPR to audiology diagnostic services. Speech-Language Pathology. The eight speech-language pathology procedures included in the 2012 MPPR policy will continue in 2013. The practice expense component of the second and subsequent therapy services furnished to the same patient on the same day will be reduced by 20% for services provided in office/noninstitutional settings and 25% for services provided in institutional settings. (For more information on the MPPR policy, see p. 6 of the 2012 Medicare Fee Schedule for Speech-Language Pathologists [PDF].) Physician Quality Reporting System CMS also has proposed changes to the Physician Quality Reporting System (PQRS), a voluntary quality reporting program that began in 2007 as an incentive payment program. PQRS will remain an incentive program through 2014, but will change to a penalty program in 2015. Providers must begin reporting in 2013 to avoid the 1.5% deduction in 2015 (see supplement below). The rule also proposes to retire 14 PQRS measures, including two audiology measures and one speech-language measure. The two audiology measures proposed for retirement—referral for otologic evaluation for patients with active drainage from the ear and for patients with history of sudden or rapidly progressive hearing loss—are noted as not endorsed by the National Quality Forum (NQF). The other two—referral for otologic evaluation for patients with congenital or traumatic deformity of the ear and for patients with acute or chronic dizziness—are also noted as not endorsed but remain as reportable measures. One speech-language Functional Communication Measure—motor speech—is endorsed by NQF but recommended for retirement without explanation. ASHA is requesting reconsideration of the retirement of these measures based on the inconsistent application of NQF endorsement. Speech-Generating Devices Under current Medicare regulations, a physician ordering a speech-generating device must have a written evaluation signed by a certified SLP. Under the proposed 2013 rule, the physician will need to document and communicate to the device supplier that the physician (or physician assistant, nurse practitioner, or clinical nurse specialist) met with the patient less than 90 days before or within 30 days after writing the order. Speech-generating devices represent four of the 55 items on a CMS list of durable medical equipment items that that can cost more than $1,000 and/or are susceptible to fraud, waste, or abuse. These four speech-generating devices in the Healthcare Common Procedure Coding System would require the in-person meetings: E2502: Speech-generating device, digitized speech, using pre-recorded messages, 8–20 minutes. E2506: Speech-generating device, digitized speech, using pre-recorded messages, greater than 40 minutes. E2508: Speech-generating device, synthesized speech, required message formulation by speech and access by physical contact with the device. E2510: Speech-generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access. In compiling the list, CMS cites a 2007 Government Accountability Office report that estimated $700 million in improper payments for durable medical equipment, prosthetics, orthotics, and supplies from April 2005 through March 2006. ASHA will express concern for the inclusion of speech-generating devices on the CMS list. Telehealth Services Although CMS addresses telehealth services in the proposed rule, these services are covered only when provided by disciplines authorized by Congress—physicians and physician extenders, nurse-midwives, clinical psychologists, clinical social workers, and registered dieticians—for specific CMS-approved procedure codes. Congress has not changed this provider list in recent years, and ASHA continues to lobby Congress and CMS to include audiologists and SLPs for the coverage and reimbursement of telehealth under Medicare. ASHA’s Comments ASHA has been working closely with CMS officials on legislative mandates and will continue to advocate, analyze the proposed rules, and prepare comments (due Sept. 4) for all issues related to speech-language pathology and audiology services. Audiologists and SLPs who provide Medicare Part B services should prepare to participate in PQRS in 2013, ensure appropriate documentation, and remain informed by signing up to receive ASHA Headlines announcements. Revising billing systems and updating fee schedules, however, are premature. Final rules for 2013 are expected to be published by November 2012. ASHA will continue to inform members of fee schedule developments through Headlines,Leader articles, and updates on the ASHA website). Quality Reporting in 2013 Affects Medicare Payments in 2015 by Lisa Satterfield Audiologists and speech-language pathologists who don’t participate in the 2013 Physician Quality Reporting System (PQRS) will see the effects of their nonparticipation in their 2015 Medicare reimbursement rates. According to a proposed 2013 rule, the Centers for Medicare and Medicaid Services (CMS) will deduct 1.5% from all 2015 Part B payments to health care providers who did not report on at least one measure in 2013. PQRS, designed to support improvements in quality of care by tracking practice patterns, began in 2007 as a voluntary incentive payment program. Providers earn an incentive payment for reporting their patient data; as the program has continued, however, the incentive payment has decreased incrementally to the current 0.5% percent of total claims. PQRS remains an incentive program through 2014, but changes to a deduction program beginning in 2015. The proposed rule includes two different levels of PQRS participation in 2013 and 2014. The first level is required to qualify for incentive payments in 2013 and 2014; the second level of participation is required to avoid deductions in 2015 and 2016. Audiologists. To receive incentive payments in 2013 and 2014, audiologists must report on 50% of eligible cases reported on claim forms for at least three measures (or for the number of measures available for reporting if fewer than three). To avoid the 1.5% deduction on 2015 and 2016 claims, audiologists must report on the claims forms for at least one measure for audiologists in 2013 and 2014. Speech-language pathologists. To receive incentive payments in 2013 and 2014, SLPs must report 80% of eligible cases reported by a registry for a minimum of three measures. To avoid the 1.5% deduction on 2015 and 2016 claims, SLPs must report by registry for at least one measure in 2013 and 2014. Clinicians who don’t meet the 2013 requirements for full 2015 payment and who bill services under the Medicare Physician Fee Schedule in 2015 will be paid at 98.5% of the fee schedule amount; those who don’t meet the 2014 benchmarks will be paid 98% the fee schedule amount in 2016. All eligible providers (those providing services to Part B Medicare beneficiaries for certain conditions, and billing for services under the Medicare Physician Fee Schedule) are subject to this adjustment. The PQRS reporting process differs for audiologists and SLPs: Audiologist participation is based on claim form submission, which includes a Healthcare Common Procedure Coding System “G” code on the claim form. Audiologists report physician referrals if a patient presents with sudden or rapidly decreased hearing loss, dizziness, ear drainage, or outer ear deformity. SLPs report their measures for adult patients with a diagnosis related to stroke through ASHA’s National Outcomes Measurement System (NOMS), an official PQRS registry. ASHA submits NOMS data on behalf of PQRS-registered participants. SLPs report on functional communication measures including spoken language comprehension, spoken language expression, motor speech, writing, reading, attention, memory, and swallowing. Clinicians should note that CMS may change the PQRS measures in each year’s Medicare Physician Fee Schedule. The 2013 proposed rule includes changes to measures in audiology and speech-language pathology (see article above). The ASHA website offers assistance on PQRS participation to audiologists and SLPs. Lisa Satterfield, MS, CCC-A, director of health care regulatory advocacy, can be reached at [email protected]. Author Notes Lisa Satterfield, MS, CCC-A, director of health care regulatory advocacy, can be reached at [email protected]. Neela Swanson, associate director of health care economics and coding, can be reached at [email protected] Mark Kander, director of health care regulatory analysis, can be reached at [email protected] Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 17Issue 10August 2012 Get Permissions Add to your Mendeley library History Published in print: Aug 1, 2012 Metrics Downloaded 70 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2012 American Speech-Language-Hearing AssociationLoading ...

You have accessThe ASHA LeaderASHA News1 Apr 2012Contractor Tightens Endoscopy Rules Mark Kander Mark Kander Google Scholar More articles by this author https://doi.org/10.1044/leader.AN2.17052012.1 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In A Medicare administrative contractor (MAC) for seven states has imposed a more stringent level of supervision than that required by Medicare for speech-language pathologists performing videostroboscopy or nasopharyngoscopy. Last fall, the Centers for Medicare and Medicaid Services (CMS) removed any national Medicare requirement for physician supervision of qualified SLPs performing video-stroboscopy (CPT 31579; Current Procedural Terminology, ©American Medical Association) or CPT 92511, nasopharyngoscopy. As with a number of Medicare requirements, however, local MACs are permitted to specify a more stringent level of supervision. In mid-December 2011, Palmetto—the MAC for California, Hawaii, Nevada, North Carolina, South Carolina, Virginia, and West Virginia—posted the following requirement: Speech-language pathologists (SLPs) are trained in basic laryngeal examination related to speech and dysfunctional swallowing conditions. Since an SLP does not have the experience or knowledge to biopsy a neoplasm or an anatomical pathologic condition, Palmetto PGA will reimburse a videostroboscopy and nasopharyngoscopy service when an SLP performs the service under the direct supervision of a physician credentialed by the hospital to perform the services. Note that when the provider setting is a hospital, “immediately available” means in an office close to the hospital or satellite department of a hospital. In addition, “physician” may include a nurse practitioner or physician assistant if allowed under state law. ASHA has contested Palmetto’s requirement and has raised the following issues: Palmetto’s rationale for requiring direct supervision appears to be that SLPs lack the experience or knowledge to biopsy. However, SLPs perform a videostroboscopy or nasopharyngoscopy to determine a functional, not medical, diagnosis. CMS confirmed this SLP role in a July 18, 2011, letter. An SLP’s inability to biopsy does not detract from the SLP’s qualifications to perform the procedures. The requirement that the supervising physician be credentialed by “the” hospital might be interpreted to mean that the procedure is approved for hospital settings only. ASHA has requested that Palmetto clarify that the procedures are covered in office settings as well. In the latest available Medicare Part B data, 86% of videostroboscopies occur in an office setting. For more information, see The ASHA Leader, Aug. 2, 2011 or visit ASHA’s Medicare reimbursement webpage. Author Notes Mark Kander, director of health care regulatory analysis, can be reached at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 17Issue 5April 2012 Get Permissions Add to your Mendeley library History Published in print: Apr 1, 2012 Metrics Downloaded 99 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2012 American Speech-Language-Hearing AssociationLoading ...

You have accessThe ASHA LeaderBottom Line1 Oct 2012Medicare Preapproval Changes Are Here Lisa Satterfield, andMS, CCC-A Mark Kander Lisa Satterfield Google Scholar More articles by this author , MS, CCC-A and Mark Kander Google Scholar More articles by this author https://doi.org/10.1044/leader.BML2.17122012.3 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In If you are a speech-language pathologist who provides services to Medicare-eligible clients, you must now request Medicare pre-approval to continue to provide services to beneficiaries whose combined speech-language pathology and physical therapy services in 2012 have exceeded $3,700 as of Oct. 1. You also may have received notification of your assigned phase for manual medical review of those beneficiaries’ claims. So, now what do you do? Step 1 The manual review process includes three phases, each with different implementation dates. Check which phase your private practice or facility has been assigned. The pre-approval process begins: Oct. 1 for providers in Phase 1 Nov. 1 for providers in Phase 2 Dec. 1 for providers in Phase 3 Step 2 Your Medicare Administrative Contractor (MAC) can tell you: Which patients may require pre-approval for continued services. The MAC’s process for submitting pre-approval requests. For telephone numbers and links to all the Medicare Part B MACs, visit the ASHA website. Providers may request pre-approval for up to 20 treatment days of services for patients who are at or near the $3,700 cap. Preapproval Requirements Regardless of the MAC’s process, the Centers for Medicare and Medicaid Services (CMS) requires that pre-approval requests include, at a minimum: Beneficiary name, Medicare claim number, date of birth, address, and telephone. Name, provider number, address, and telephone of the physician/nonphysician provider certifying the plan of care. Name, provider number, address, and telephone of the facility or private practice providing treatment. The number of treatment days requested, expected date range of service, and date of submission. Medical justification for continued treatment, including evaluation and/or re-evaluation for the plan of care (POC); certification of the POC; objectives and measureable goals and any other document requirements of the local coverage determination; progress reports and treatment notes; any orders for the additional treatment. If pre-approval is denied, you may submit a new pre-approval request only if you have new or additional information to include in the request. Why the New Regs? The Middle Class Tax Relief and Job Creation Act of 2012, passed by Congress in February, mandates CMS to conduct a “manual medical review” of claims that exceed $3,700 on or after Oct. 1 (The ASHA Leader,July 3,Aug. 28). The manual medical review is in effect Oct. 1 through Dec. 31, and may or may not be mandated for 2013. Author Notes Lisa Satterfield, MS, CCC-A, director of health care regulatory advocacy, can be reached at [email protected]. Mark Kander, director of health care regulatory analysis, can be reached at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 17Issue 12October 2012 Get Permissions Add to your Mendeley library History Published in print: Oct 1, 2012 Metrics Current downloads: 39 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2012 American Speech-Language-Hearing AssociationLoading ...

You have accessThe ASHA LeaderPolicy Analysis1 Dec 2012Medicare Changes Some Audiology Codes for 2013 Lisa Satterfield, MS, CCC-A Neela Swanson and Mark Kander Lisa Satterfield Google Scholar More articles by this author , MS, CCC-A, Neela Swanson Google Scholar More articles by this author and Mark Kander Google Scholar More articles by this author https://doi.org/10.1044/leader.PA2.17152012.8 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In If you’re an audiologist who provides services to Medicare Part B beneficiaries, you need to know about some provisions in the 2013 Medicare rules that will affect reimbursement, quality reporting, and billing for some procedures. Here’s how the Medicare Final Rule that starts Jan. 1 applies to audiologists. CPT Code Changes The final fee schedule includes several new CPT codes (Common Procedural Terminology, © American Medical Association) used by audiologists for electrophysiologic evaluations and intraoperative monitoring. Seven nerve conduction study codes (95907–95913) that include motor, sensory, and mixed nerve conduction studies replace the H-reflex codes (95934 and 95936). Tests must be formed with separate electrodes for stimulating, recording, and grounding on only the nerves that apply to the specific diagnosis. The continuous intraoperative neurophysiology codes, 95940, 95941, and G0453, represent monitoring, testing, and data interpretation during surgical procedures. The codes mandate continuous attendance by a professional qualified to interpret the testing and monitoring, and require immediate communication directly with the operating room. The codes include the ongoing monitoring time (distinct from the performance of baseline studies). The two continuous intraoperative neurophysiology monitoring codes, 95940 (in the operating room) and 95941 (outside the operating room), replace the deleted 95920 (intraoperative neurophysiology testing, per hour). However, 95941 may not be used for Medicare beneficiaries, because it allows a provider to monitor several patients remotely at the same time. Because the Centers for Medicare and Medicaid Services (CMS) allows a provider to monitor only one patient at a time, it created G0453, which covers continuous remote (outside the operating room) monitoring for one patient. Both 95940 and G0453 are billed in units of 15 minutes. Additional information on the new codes will appear in a future issue of the Leader and on ASHA’s New and Revised CPT & HCPCS Codes For 2013 webpage. Physician Quality Reporting System The final rule emphasizes that audiologists must participate in the Physician Quality Reporting System (PQRS) in 2013 or be penalized 1.5% on all Medicare Part B claims in 2015. This outcome measure system has been an incentive program, with providers receiving a bonus for participating. In 2015, however, the incentive system changes to a penalty system, and providers who don’t participate in 2013 will incur a 1.5% penalty on their 2015 claims. The incentives and penalties apply to private and group practice audiologists who bill Medicare Part B using their individual National Provider Identifier (NPI) on the claim form. Institutional providers, such as audiologists employed in hospitals, are not included in the rule. There are only two conditions audiologists must report: referrals to otologists for congenital or traumatic ear deformity and for dizziness. Audiology PQRS information in the final rule was inconsistent, with the text naming only two conditions and the accompanying tables listing four. CMS subsequently clarified that despite the information in the table, two measures are being deleted. Correct participation is based on the diagnosis of the patient and the procedures completed, not if the referral for the listed conditions was performed or even necessary. For example, an audiologist performs a comprehensive audiology evaluation (CPT 92557) on a patient with benign paroxysmal positional vertigo (BPPV). Even if the patient is already under the care of an otologist or physician for BPPV, the audiologist must report G8857 (no referral, patient already under the care of a physician for acute or chronic dizziness). Each reportable condition has a similar code to report if referral is not necessary or made. In 2013, audiologists must report on at least one condition consistently for the entire year to avoid the 2015 penalty. In future years, however, providers will need to report on both conditions for at least 50% of beneficiaries who have the diagnoses and procedure code that require reporting. ASHA, in collaboration with other audiology organizations, has created various materials to help audiologists report correctly. Audiologists should become familiar with the procedure and diagnosis codes that require reporting, and include the G-codes on documentation and claim forms when appropriate. Reimbursement Rates Audiologists will see changes in 2013 reimbursement rates because of two factors: the conversion factor established by a statutory formula, and changes in the “practice expense”—one of several costs factored into the value of any given procedure code—for audiology diagnostic codes. Practice Expense The value of each procedure code is calculated by separating the cost of providing the service into relative value units (RVUs) in three components—professional work, technical expenses (practice expense), and professional liability insurance (malpractice). The total RVUs for each service is the sum of the three components (components are adjusted for geographical differences); the RVUs for any particular CPT code are multiplied by the conversion factor to determine the corresponding fee. In 2013, audiologists will be affected by the final year of a four-year phase-in of practice expense value changes, the result of updated practice cost surveys. These changes have decreased rates for many audiology codes, mostly because the costs of operating an audiology practice are substantially less than those of a medical practice. However, in the last few years, ASHA has worked with other audiology and physician groups to have the American Medical Association transfer audiologists’ time and effort out of the practice expense and into professional work. Professional work RVUs do not change over time, unlike practice expense values that fluctuate according to CMS payment formula policies. This effort is not yet complete, leaving some codes with only practice expense and malpractice components. Work Values for Otoacoustic Emission Codes Despite efforts by ASHA and the American Academy of Audiology, CMS has not corrected the professional work value assigned to two codes for evoked otoacoustic emissions evaluations, CPT 92587 (for three to six frequencies) and CPT 92588 (more than 12 frequencies). The two organizations protested the work value assigned to the codes in 2012, and presented evidence to a CMS panel that the RVUs did not accurately represent the work involved in the procedures (“ASHA Argues for Higher Valuation of OAE Codes,” The ASHA Leader, May 15). Although the panel recommended higher work values, CMS disagreed with the recommendation and has maintained its original decision to assign work RVUs of 0.35 for 92587 and 0.55 for 92588. Conversion Factor CMS has established a 2013 conversion factor of $25.0008, a figure that is 26.5% lower than the 2012 factor. Although this rate is mandatory because of a statutory formula known as the sustainable growth rate (SGR), Congress has enacted legislation to change the factor almost every year since the SGR was implemented. It is anticipated that Congress will once again act to prevent this reduction by the end of 2012. ASHA will post new fees for audiology codes when congressional action is complete—or when it becomes clear that Congress will choose not to act. Check ASHA’s Billing & Reimbursement website for updates. Hospital Outpatient Prospective Payment System Rates for key hospital-based outpatient audiology services under the Outpatient Prospective Payment System increase, on average, in 2013. The rates vary from a drop of 3.3% to an increase of 4.4% over 2012: The bundled vestibular evaluation (92540) has increased by 3.7%. The fee for cochlear implantation (69930) has increased by almost 5% to $30,300, a figure intended to cover the device and surgical costs, but yields a variable loss for many hospitals. The rate for an auditory osseointegrated implant has increased by 3.5%, up substantially from the initial proposed 3.8% decrease. Author Notes Lisa Satterfield, MS, CCC-A, director of health care regulatory advocacy, can be reached at [email protected]. Neela Swanson, associate director of health care economics and coding, can be reached at [email protected]. Mark Kander, director of health care regulatory analysis, can be reached at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 17Issue 15December 2012 Get Permissions Add to your Mendeley library History Published in print: Dec 1, 2012 Metrics Downloaded 61 times Topicsasha-topicsleader_do_tagasha-article-typesCopyright & Permissions© 2012 American Speech-Language-Hearing AssociationLoading ...