Imagine this scenario: John Smith is a healthy 55-year-young man. He likes long walks on the beach, has a Siamese cat named Snuffles, owns his own contracting company, and has a beautiful wife whom he met in college, and he feels like things are going his way. One morning, during his normal routine, John looks at the beige color on the bathroom wall in front of him, but he can't move his head, his mouth stands wide open, and he can't utter a single word. He returns to the living room where his wife puts John in their car and drives him to the local emergency room. The emergency room doctor tries to ask John some simple questions, but John can't speak. He is wheeled across a maze of rooms until he arrives at the hospital radiology department. The technician performs a CAT scan, and John is told that the emergency care doctor will know the results. A couple of hours later, the emergency care doctor tells John that he wants to admit him to the hospital for more tests. John's wife is told, "Don't worry about insurance; you have the best insurance out there." While being taken to his hospital bed, John has a seizure. The tip of his tongue is badly bitten, but the ER doctor comes in and repairs it. John has no memory of the seizure, nor of the hospital visit.
After a two-day stay in the hospital, John is told that he had a stroke. His memories are wiped as clean as if you wiped your hard drive. Back at home, a van shows up and out walks a woman in a nurse's uniform. Her name is Tiffany, and she is a nurse, as well as a speech therapist. She will use due diligence to regain John's memories. Tiffany tells John, "Don't worry about the cost; my services are covered by your insurance." John asks her, "What the heck happened?" Tiffany says, "Mr. Smith, you had a stroke!" John cannot believe it; he isn't that old. Tiffany also tells John that he now has a medical condition called aphasia, which is a stroke-related injury. John saw on the news that his favorite movie actor, Bruce Willis, recently retired from acting, because he too has aphasia.
The lessons are intense because Tiffany must work to rebuild John's brain. He has to learn how to walk normally, how to use his fingers like before, how to use money, how to shop for groceries, and how to cook for himself. John's work memories as a contractor are still alive in his brain. However, Tiffany tells John that she has bad news; he cannot drive his car like he previously did. Tiffany also tells John that she wants him to be seen by a mental health professional. John learned that people with aphasia may have bouts of depression, and in order to deal with this life change, a mental health professional may be necessary. Tiffany also tells John that she wants him to go to his local Social Security office and apply for Medicare disability benefits. His medical bills may be denied by his insurance for various reasons, and because he may not be able to work anymore, his job will eventually end, and workers compensation may deny his medical care benefits. John understands that his enrollment in the best health insurance may not be permanent, whereas his aphasia is likely permanent.
What is Aphasia?
According to aphasia.org, "Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write. Aphasia is always due to injury to the brain-most commonly from a stroke." The main treatment for aphasia is speech and language therapy. The person with aphasia relearns and practices language skills and learns to use other ways to communicate. Family members often participate in the process, helping the person communicate.
Aphasia Bill Of Rights
According to the National Aphasia Association:
People with aphasia have the right to:
- Be told, as soon as it is determined, preferably by a qualified speech language pathologist (SLP), both orally and in writing, that they have "aphasia" and given an explanation of the meaning of aphasia.
- Be provided, upon release from the hospital, with written documentation that "aphasia" is part of their diagnosis.
- Be told, both orally and in writing, that there are local resources available to them, including Aphasia Community Groups in their areas, as well as national organizations such as the National Aphasia Association (NAA).
- Have access to outpatient therapy to the extent deemed appropriate by a qualified speech-language pathologist (SLP).
- Give their informed consent in any research project in which they are participating.
- Demand that accrediting healthcare agencies and healthcare facilities establish requirements for and competency in caring for people with aphasia.
- Have access to information in their most functional language through a qualified professional, or through an interpreter and/or printed material, and access to culturally sensitive services when the person with aphasia speaks a language different from English and/or is from an ethnically/culturally diverse background.
Currently, aphasia is a covered service by every health benefit plan.
The ICD-11 code for aphasia is MA80.0.
Currently, CPT code 92506 is billed for the evaluation of speech, language, voice, communication, and/or auditory processing. This code is considered an "umbrella" code and will be replaced with four new, more specific evaluation codes related to language, speech sound production, voice and resonance, and fluency disorders. The new CPT codes for speech/language evaluations are 92521, 92522, 92523, and 92524.
John will continue to live a simple, normal, everyday life, but he has challenges. During his therapy session with Tiffany, he writes down a grocery list of things to buy at the store. He has to review his list to see if he left anything off or wrote something down incorrectly. He has to memorize where an item is at the store. He knows that the milk is at the front of the store and next to it are the eggs; he has to check to make sure that they are not broken, and that there are 18 eggs in the carton. To someone without aphasia, they take things for granted, but John's simple journey to the store is not simple. He has no access to money because he doesn't know how to use a credit/debit card and has trouble making change at the check-out. People walking around the store look at John like he is a normal, everyday person. John's mental health nurse speaks with John about his depression because John wants to be normal. He can't speak normally because his aphasia causes him to stutter or to pause his speech. In his job as a contractor, John needs to speak to clients, but he must speak slowly so he does not stutter. The one thing he doesn't want is to lose a client.
After several months and numerous visits to a Medicare-approved doctor, John walks to the mailbox and inside is a letter from a Medicare office in Pennsylvania. Inside is a check and a brand-new Medicare ID card. The check is for John's Medicare disability, which he used to pay some past due bills. While John was in the hospital, a doctor came to see him in his hospital room. That doctor is now his primary care provider who now sees John once every 3 months on an outpatient basis and prescribes medication for his aphasia and seizures. His outpatient visits and medication are paid by Medicare, which will now be his primary health benefit plan, and his former health insurance will now be his secondary health benefit plan. Now, when John seeks care from his doctors and specialists, he has to show both of his health benefit ID cards. John's wife made a copy of his insurance ID cards and laminated them to put them around John's neck when he goes in for a medical care visit. John's wife also went shopping online to buy a medical alert ID badge for John to wear around his neck. He also has a fanny pack around his waist to carry his phone, house keys, and emergency medication.
John doesn't smile anymore, because when he smiles, his facial muscles are semi frozen, and he thinks he looks a lot like Lurch from the Addams Family.
Editor's note: All of John's loved ones, colleagues, and clients notice his smile, appreciate the insight he still brings to the industry, and hold onto hope for a full recovery. Because, although aphasia affects an individual's ability to process language, it does not affect intelligence. And, while a slow process, improvement could continue for decades. Read more about aphasia at aphasia.org to better understand the disorder and support those living and communicating with aphasia.
Steve Verno, CMBSI, CHCSI, CEMCS, CMSCS, CPM, CHM is a Professor of Medical Coding and Billing Instruction at Florida Metropolitan University.