Module 3 Comprehensive Notes – Voice Evaluation, Interviewing & Billing

Gathering Comprehensive Case History

• Never assume the electronic chart you are viewing is complete.

  • Example: Medicare + supplemental insurance holders may consult multiple hospital systems (e.g., Cox, Mercy). Information lives in separate EHRs (Cerner vs. Epic, etc.).

  • In any city with multiple health systems, records are often siloed by insurance‐driven provider networks.

• Practical strategies:

  • Ask the patient where else they have been treated; request outside records.

  • Use health-information exchanges when available.

  • Expect delays when tracing records through different insurance portals.

Insurance Structures and Information Fragmentation

• Managed Care definition:

  • Corporation contracts with a limited panel of providers.

  • Patients pay higher out-of-network costs, so data stay in-network.

• Straight Medicare + supplement:

  • Patient free to see any provider → chart data scatter even more.

• Ethical implication: Clinician must “dig” for the full picture before forming conclusions.

Validating Patient-Provided Information

• Do not take self-report as “gospel.”

  • Patients may have language disorders, cognitive impairment, or simply be poor historians.

  • Confabulation is common; believable stories can be entirely false.

• Verification loop:

  • Ask clarifying “who / what / when / where” questions.

  • Cross-check with accompanying family.

  • Re-examine written intake vs. spoken narrative.

• Motto: “Listen, collect, but always validate.”

Interview Techniques and Active Listening

• Quality of data depends on how well you actively listen.

• Mirroring principles:

  • Subtle match of body posture, facial affect, and energy level increases patient comfort.

  • If patient leans back with arms crossed, clinician should not project the opposite extreme.

• Avoid emotional overidentification (e.g., breaking down in tears alongside the patient).

Non-Verbal Communication Nuances

• Maintain gentle eye contact; avoid constant computer gaze.

• Lean forward slightly to show engagement.

• Eliminate distractions:

  • Smart-watch notifications break rapport—remove the watch.

• Place both digital and analog clocks in therapy spaces.

  • Additional cognitive data: inability to read an analog clock may hint at visuospatial or cognitive deficits.

Note-Taking While Maintaining Rapport

• Learn to write while looking at the patient or explicitly pause: “Let me jot that down.”

• Continuous typing without eye contact forfeits observational data such as vocal effort, breathing pattern, facial asymmetry, etc.

Observation During Patient Interview

• Use informal observation simultaneously:

  • Spontaneous voice quality vs. performance during structured tasks.

  • Discrepancies reveal compensations or situational variability.

• Always pair with at least one formal task set to corroborate impressions.

Acoustic Measures in Voice Assessment

• Clinician-friendly apps available; a link will be provided separately.

• Caveats:

  • Every microphone colors the spectrum; every speaker colors playback.

  • \text{Human ear} > \text{any mic + speaker}

  • Normative databases are expressed as ranges, not absolutes, due to equipment variability.

• Let auditory‐perceptual judgment, palpation, and patient report trump acoustic printouts when incongruent.

Medical Clearance and Legal Requirements for Voice Therapy

• A voice evaluation MAY occur without prior medical exam.

• Therapy (treatment) CANNOT begin without medical clearance nationwide.

  • Preferably from an ENT; at minimum a medical provider ruling out disease.

• Insurance caveats:

  • Many plans will not reimburse evaluation if referral is absent.

  • State practice acts may layer additional restrictions.

Diagnostic Coding Systems

• ICD-10 = International Classification of Diseases, 10th Revision.

  • SLPs have speech-specific codes (e.g., aphasia, dysphonia) but cannot code medical entities like “tumor.”

  • Physician may also code dysphonia; overlap allowed.

• Distinction: SLP formulates a communication diagnosis; insurer demands an accompanying MEDICAL diagnosis (injury or illness) for payment.

  • Strategy: call the physician’s nurse/MA to obtain missing medical ICD-10 code.

CPT Codes and Billing Mechanics

• CPT = Common Procedural Terminology (describes WHAT you did).

  • Evaluation: 92506 (speech, language, cognitive, or voice evaluation).

  • Treatment: 92507 (speech, language, cognitive, or voice therapy).

• Example workflow:

  1. Patient self-refers → perform 92506.

  2. Identify probable voice disorder, but with unknown etiology → refer to ENT.

  3. After clearance, begin 92507 sessions.

• CMS (Centers for Medicare & Medicaid Services) rules drive federal reimbursement; Congress allocates CMS budget.

  • Medicare = payroll-funded entitlement.

  • Medicaid = needs-based entitlement jointly funded by state + federal dollars.

Laryngeal Imaging: VSO and Other Modalities

• Imaging options:

  • Mirror examination (oldest, cheapest).

  • Rigid or flexible endoscopy with “straight” light.

  • Video Stroboscopy (VSO): synchronized flashing gives apparent slow-motion view of fold vibration.

• Historical note: Developed jointly by SLP + ENT to connect movement patterns with acoustic output.

• Scope of practice distinctions:

  • SLP may perform imaging for FUNCTION only (movement patterns).

  • ENT must review STRUCTURE (tumors, leukoplakia, cysts, etc.).

• Workflow in some clinics:

  • SLP captures VSO, uploads to cloud; ENT reviews asynchronously, bills an interpretation code.

  • SLP may discuss suspected findings but cannot issue structural diagnosis.

• Ethical language to patient: “I observed some strain; I will review with the doctor and get back to you.”

Collaboration with ENT and Other Medical Professionals

• Build relationships with ENT offices; frontline communication usually through the nurse/MA.

• ENT earns primary revenue from surgery; therefore may welcome SLP assistance with functional imaging.

• SLP may guide ENT’s attention ("do you see anterior glottal gap?") but final medical diagnosis remains physician’s domain.

Structuring Evaluation Sessions

• Time blocks vary by setting:

  • Some outpatient clinics book 1-hour eval slots.

  • Instructor’s preference: 1.5-hour slot → allows evaluation (92506) plus immediate treatment initiation (92507) and home program.

• In hospital ENT clinics, visits may be segmented: imaging first, formal eval later.

Practical Tips and Common Pitfalls

• Avoid conspicuous gestural tics that distract patients (e.g., repetitive finger tapping).

• Monitor your own affect; overly exuberant style can “freak out” flat-affect clients.

• Keep both digital and analog clocks visible (patient cognition gauge + clinician time management).

• When using smart devices for acoustic recording, understand their limitations; always compare to live perceptual judgment.

• Remember: You are a communication specialist—model optimal communication in every interaction.