Eli's Rehab Report

 Plus: Stay tuned for more stuttering ICD-9s in October.

In the last issue, you learned how to build up your practice's stuttering services. Billing for them, however, is a whole other ball game. So don't get hit with a curveball from your payers.

"Medical insurance is generally reluctant to reimburse for stuttering, especially if it is for an adult patient who has a history of chronic stuttering," notes Jane Fraser, president of the Stuttering Foundation.

First things first: Before you begin treatment, ask the patient to check his insurance policy to see whether his therapy would be covered -- and if not, see if the patient would be willing to pay out-of-pocket, Fraser continues.

Right now, there is only one ICD-9 code available for stuttering: 307.0. "If the patient is exhibiting neurogenic stuttering after a stroke or as a result of another neurological condition, code for the primary condition first; then use 307.0 as the secondary code," Fraser says. "If the patient is seeking services for stuttering only (e.g., through such a change would be with a short-term goal like,

'During conversational speech, average duration of stuttering moments will decrease by 50 percent,'" Fraser offers.

Measuring change in attitudes and confidence can be trickier, though, and Fraser suggests showing progress by using self-rating scales. "Reflect on how the patient's lack of confidence might interfere with his ability to use the phone to call 911 to communicate pain or his life being in danger," she suggests. "Then, write a goal that addresses this limitation, such as, 'Client will demonstrate increased confidence in using the phone, as represented by pre-post rating change of at least two points on a 1-10 confidence self-rating scale.'" an outpatient clinic), then 307.0 is the appropriate primary code to use."

Heads up: The ICD-9 code set is supposed to include additional, more specific stuttering codes come Oct. 1, 2010, says Nan Bernstein Ratner, Ed.D., CCC-SLP, F-ASHA, professor and chairman for the Department of Hearing and Speech Sciences at the University of Maryland: "The old code, 307.0 will be reserved for what we used to call psychogenic stuttering, but will now be called 'adult onset fluency disorder,' which excludes three other codes."

Those three codes are:

• 315.35 (Childhood onset fluency disorder). This will be the new default code, which includes stuttering and cluttering, Ratner says.
• 438.14 (Fluency disorder). This code went into effect Oct. 1, 2009.
• 784.52 (Fluency disorder in conditions classified elsewhere). Those conditions could include a head injury, Parkinson's, etc., Ratner continues.

Next: When choosing a CPT code, keep it simple.

"The CPT is going to be plain old 92507 (Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual) for your treatment and 92506 (Evaluation of speech, language, voice, communication, and/or auditory processing) for the evaluation; there are no special codes for stuttering," Ratner says.

As with any therapy claim, you must document medical necessity for insurance to reimburse.

Tip: Check out the insurance plan's handbook for its definitions of medical necessity, and "clearly link the patient's presenting symptoms with the medical necessity definition," Fraser suggests.

To amp your documentation up even more, "consider how this patient's stuttering would interfere with her ability to make a 911 call, communicate with a physician, or stop an assault on her life if needed," Fraser says.

Then, "present any research evidence available to support the treatment plan you are suggesting and what typical fluency you expect for a patient of this age."

More ammo: Your claim will look even more medically necessary if you use medically-oriented terms to characterize the patient's speech. "For example, if a patient presents with excess tension during a moment of stuttering, describe the tension as 'laryngeal (or articulatory) hypertension,'" Fraser says.

Other terms to add to your arsenal may include, "irregular vocal fold vibration, inadequate respiratory support for speech, abrupt onset of phonation, and involuntary muscle tremor of the oral (or laryngeal) mechanism," Fraser adds.

Your documentation must also show the patient is making reasonable progress for your payers to reimburse. But don't get hung up on your patients with chronic stuttering problems.

For these patients, reasonable and appropriate progress could be and increase in overall fluency, having less severe moments of stuttering, or having changes in confidence, Fraser says. So you need to think strategically about how you'd document these changes.

Example: You have a patient who presents with a stable frequency of stuttering, and the severity decreases as a result of therapy. "One way to represent such a change would be with a short-term goal like, 'During conversational speech, average duration of stuttering moments will decrease by 50 percent,'" Fraser offers.

Measuring change in attitudes and confidence can be trickier, though, and Fraser suggests showing progress by using self-rating scales. "Reflect on how the patient's lack of confidence might interfere with his ability to use the phone to call 911 to communicate pain or his life being in danger," she suggests. "Then, write a goal that addresses this limitation, such as, 'Client will demonstrate increased confidence in using the phone, as represented by pre-post rating change of at least two points on a 1-10 confidence self-rating scale.'"