Medicare, Medicaid & Billing on the Praxis 5331

Reimbursement rules dominate real-world medical SLP practice — and the Praxis tests enough of them to matter. You don't need to know billing at the level of a medical coder, but you do need the framework of Medicare/Medicaid coverage, skilled vs. maintenance care, and the documentation vocabulary the exam uses.

What the Praxis tests about reimbursement

• Medicare Part A vs. Part B — what each covers.
• Skilled therapy vs. maintenance care.
• Medical necessity documentation.
• Basics of ICD-10 (diagnosis) and CPT (procedure) coding.
• The 8-minute rule for timed CPT codes.
• Plan of care and physician certification.
• Denials, appeals, and advance beneficiary notices (ABNs).

Medicare Part A vs. Part B — the differential

• Part A. Inpatient hospital, skilled nursing facility (SNF), home health, hospice. SLP is bundled into a per-day or per-episode rate. Documentation drives length of stay.
• Part B. Outpatient services (hospital outpatient, private practice, some SNF beyond covered days). SLP is billed per encounter using CPT codes. There is an annual therapy threshold — beyond it, additional documentation is required to continue treatment.

Praxis rule of thumb: if the setting is described as "outpatient clinic," it's Part B. If it's the first 100 days of a SNF stay following a qualifying hospital stay, it's Part A.

Skilled vs. maintenance care

• Skilled therapy requires the expertise of a licensed SLP. Includes evaluation, treatment planning, and providing intervention that requires clinical judgment.
• Maintenance therapy is also skilled if it requires the judgment of an SLP to design or safely deliver — even if the goal is maintaining function, not improving it. Since Jimmo v. Sebelius (2013), Medicare cannot deny coverage simply because a patient isn't improving.

Praxis trap: "the patient has plateaued so services must be discontinued" is wrong. If skilled judgment is required to prevent deterioration or maintain function, services continue.

Medical necessity — the documentation frame

Every reimbursable session must be documented as medically necessary. Elements to include:

• Objective, measurable functional deficit.
• Skilled interventions used (not activities alone — the reasoning behind them).
• Response to intervention (progress or clinical rationale for continued need).
• Plan for the next session.

Documentation that reads "patient did articulation drills" fails. Documentation that reads "provided cueing hierarchy for /s/ in conversation; faded from tactile to verbal cues with 60% accuracy; will progress to independent production" meets the skilled bar.

ICD-10 and CPT — the basics

• ICD-10 codes describe the diagnosis (e.g., R47.01 Aphasia, R13.10 Dysphagia unspecified, F80.2 Mixed receptive-expressive language disorder). SLPs typically list a treatment diagnosis, but the physician assigns the medical diagnosis.
• CPT codes describe what you did. High-yield codes for SLPs:
  • 92507 — treatment of speech, language, voice, communication (untimed).
  • 92508 — group treatment.
  • 92521–92524 — evaluations (fluency, sound production, language, voice).
  • 92526 — treatment of swallowing dysfunction (untimed).
  • 92610 — evaluation of oral and pharyngeal swallowing.
  • 92611 — videofluoroscopic swallow study (motion fluoroscopic).
  • 96125 — standardized cognitive performance testing (timed, per hour).

Timed vs. untimed codes and the 8-minute rule

Most SLP treatment codes (92507, 92526) are untimed — one unit per session regardless of length. Some SLP codes (96125) are timed. For timed codes billed to Medicare, the 8-minute rule governs how many 15-minute units you can bill:

• 8–22 minutes → 1 unit
• 23–37 minutes → 2 units
• 38–52 minutes → 3 units
• 53–67 minutes → 4 units

You do not apply the 8-minute rule to untimed codes. Praxis-level questions rarely ask for exact unit math but do test whether you know timed vs. untimed and that the 8-minute rule is a Medicare Part B convention.

Plan of care and physician certification

• Medicare Part B requires a signed plan of care within 30 days.
• Recertification is required at least every 90 days.
• The plan of care must include diagnoses, long-term treatment goals, and type/amount/frequency/duration of services.
• SLPs can evaluate and initiate treatment without a physician referral in many states, but Medicare Part B still requires physician certification of the plan.

Medicaid — the differences

• Federally funded, state-administered. Rules vary substantially by state.
• Covers children (including through EPSDT — Early and Periodic Screening, Diagnostic, and Treatment) more comprehensively than Medicare does adults.
• Schools can bill Medicaid for SLP services delivered to eligible students under IDEA.
• Prior authorization is common for many treatment codes.

Advance Beneficiary Notice (ABN)

When Medicare may not cover a service, the patient must be given an ABN before the service is provided. The ABN explains why Medicare may deny coverage and lets the patient decide whether to proceed and pay out of pocket. Praxis-tested scenario: a patient has exceeded the therapy threshold; the SLP believes services are still medically necessary but coverage isn't guaranteed. Correct action: provide an ABN.

Denials and appeals

Medicare denials come with specific reason codes. The appeal process has five levels:

1. Redetermination by the Medicare Administrative Contractor.
2. Reconsideration by a Qualified Independent Contractor.
3. Administrative Law Judge hearing.
4. Medicare Appeals Council review.
5. Federal district court.

You don't need to memorize each level for the Praxis, but you should know appeals exist and that "denied" is not the final answer if the service was medically necessary.

Compliance and ethics intersections

• Never bill for services not rendered.
• Never bill for a longer session than actually occurred.
• Never upcode (bill a higher-complexity code than the service warranted).
• Never bill for services delivered by an unlicensed provider as if delivered by you.

These are ASHA Code of Ethics violations and federal fraud issues. See our ethics scenarios guide.

What to skip

You do not need to memorize specific CPT modifiers, exact annual threshold dollars (they change), or state-specific Medicaid manuals. The Praxis tests the frameworks: Part A vs. B, skilled care, documentation for medical necessity, and the ethics of billing.