CMS's NEW Pediatric G Code Explained: What Every SLP Needs to Know

CMS surprised speech-language pathologists with a proposed pediatric G code, creating new questions about reimbursement, billing, and the future of pediatric speech therapy.

In this episode, Jeanette Benigas, PhD/SLP, is joined by billing expert Rick Gawenda and pediatric private practice owner Emily Watkins, MCD/SLP, to break down what the proposed G code actually means, who it applies to, and why it matters far beyond Medicare.

Topics include:
• Who the proposed pediatric G code applies to
• Why commercial insurance and Medicaid may choose different billing paths
• Timed CPT codes vs. the proposed G code
• How reimbursement could change for pediatric practices
• Operational challenges for clinics and business owners
• Why giving payers multiple billing options may create inconsistencies
• The risks surrounding untimed codes and future payer audits
• Why understanding RVUs and practice expense matters
• What clinicians and practice owners should consider before submitting comments to CMS

Whether you're an employee, private practice owner, school-based SLP, or administrator, these proposed coding changes have the potential to affect your reimbursement, documentation, scheduling, and future practice.

This episode is designed to help you understand the proposal, not tell you what position to take, so you can make informed decisions on how to comment before the CMS comment period closes.

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Creators and Guests

Host

Jeanette Benigas, PhD/SLP

Host of Fix SLP

What is Fix SLP: Advocacy & Accountability in Speech-Language Pathology?

Fix SLP is an SLP Podcast by Jeanette Benigas, PhD, about advocacy, autonomy, and reform in Speech-Language Pathology. This show exposes credentialing gatekeeping, dismantles CCC requirements, and helps SLPs advocate for change. Each episode equips SLPs with tools to reclaim their profession. Subscribe now and join the movement transforming speech-language pathology. Follow @fix.slp on Instagram and TikTok. Visit fixslp.com.

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[00:00:00] Welcome to Fix SLP, the podcast shaking up the field of speech-language pathology. We're calling out the barriers that hold clinicians back, fixing broken systems that limit our care, and giving the power of our profession back to the people who live it every day. This is where fearless clinicians come together.

It's time to change the field, with our voices, leadership, and advocacy leading the way. So let's Fix SLP

Welcome back. It's Jeanette. It's been a little bit. It's been a minute since I've had a podcast. Um, May, May-cember took over my life. I think a lot of you saw I had a family member in the ICU, which spiraled right into summer and caregiving. And, um, I have been working on a few things behind the scenes, but also continuing to track our 92507 issue.

[00:01:00] So we're here today. I am... Well, I'm, I should say, I should mention, I'm coming to you from our nation's capital, Washington, DC. Because of my work with Fix SLP, I was nominated for and then elected to be a, um, voting delegate at the Girl Scouts of the USA Triennial Business Meeting. So I'm actually back at the same convention center that ASHA was at this year, um, listening to 13-year-olds debate rules, that are very tiring.

So it is 10:00 PM. We are gonna try to keep this as brief and as direct as possible. Um, I have two guests with me today. I have Rick Gawenda back. I know you've all been waiting to hear from Rick. And I, I have my friend Emily Watkins. Uh, Rick, I'm gonna have you remind everybody who you are. And then Emily, I'll have you share about what, who you are and what you do.

Thanks for having me, Jeanette. I'm Rick Gawenda. I am a physical [00:02:00] therapist, believe it or not, for, uh, 35 years. So I kind of grew up in the hospital system. I worked my way into hospital administration. And also my wife and

I and another bus- business partner had a couple private practices that were PT-only. Had those for 17 years. But also during all that time, for 23 years, a consultant in outpatient PT, OT, and speech therapy, really to kind of the business compliance side, so the documentation, the, the coding, the billing, denials, appeals, et cetera, and a pretty good background on, on how a CPT code becomes a CPT code and how it gets valued and helping businesses prepare, you know, budgets and get ready for that next year when payment changes Well, thank you for having me.

I am actually on vacation right now, so bear with me. Uh, but I'm Emily Watkins. I'm a speech therapist by trade. I have had a peds outpatient clinic for, well, I'll just say since 2018. Y'all can do the math. But less than 10 [00:03:00] years, more than five, somewhere in there. We do PT, OT, speech, and I have two locations.

I'm very passionate about helping business owners. I think that peds outpatient is something very special, and I think that it should be preserved, and it's just something that's always been a part of me since I was in gradu- graduate school. But it's really impacted me in the last, obviously, couple of months especially as, as much as everybody else.

So I'm here to help, I'm here to educate, I'm here to learn, but I'm also here, um, you know, as a business owner that, you know, obviously wants to see us, um, continue to thrive. And you can find Rick, Gawenda Seminars is his social media handle. But Emily has been really involved. Fix SLP is a business page, so you can't go there and have discussions.

Emily, tell us the name of the Facebook group that you started It is Speech Therapy Advocacy Alliance. I started that just as a place to where I could help disseminate information with a lot of [00:04:00] this 92507 and create discussion, but also clear up some misinformation. I feel like I have good networking with being at conferences and, and, and a ton of business owners across the country that are brilliant.

And, um, experts like Rick, and you have been in- integral in this too, and so I just, I felt like it was the time for a, a national page for advocacy that we could have some conversations. So we just started that. I think we almost have, like, 5,000 members, which is insane. Never thought it was going to be that, but I'm really excited about it.

And really, I'm more excited that we can help each other out and through this, but in other things. There's gonna be other things come up. This is not gonna... Unfortunately, this is not gonna be the last. So, um, I just think it's a good way to, to connect with people. Not connected with Fix SLP. I am not a moderator.

I am in there, and I will jump in, but it is Emily's thing. But it's a good way to kinda take the stuff you hear from Fix SLP and talk about things [00:05:00] and process it together because we can't really do that on my platforms, 'cause I don't have time to moderate, okay? You just heard what I'm doing. So I asked Emily, because she's private practice pediatrics.

I'm an adult person, and I have very serious concerns, have been since the beginning, about how this is gonna i- impact skilled nursing facilities. We will do a separate podcast on that. Maybe next week I'll come to you. I have to have time to get my thoughts together because this hit me like it has hit all of you.

I've had to process it as well. So I also wanna say, lots of people were asking me for my immediate reaction after the codes were posted. I did a very short video, and I will apologize, and I did say at the top of that epi- that little video, and more than once, "Hey, I haven't had a chance to look at this.

This is my first reaction. I will have time to process it and come back to you." So I did misstate that this G code would be required to be 60 minutes. That was a [00:06:00] mistake that I made, so I apologize for that. I have been able to now read and learn and talk to Rick and talk to others. So we're gonna bring you correct information, or at least as well as we can today.

And, um, what I wanna start with, that we'll have Rick answer, we've got values for our 10 sets of codes, but then this surprise G code turning sort of mo- not really modifying, but kind of replacing 92507 for, for pediatrics, which is zero to 21. But I think most SLPs don't understand who that applies to. So Rick, G code only, not the 10 codes.

G code, tell us who that applies to right now as it stands and how it might impact some of the other insurances? So, you know, obviously CPT codes, they have to go through the AMA process, the RUC and all of that. Uh, this G code that Medicare, [00:07:00] you know, surprised us all with, I think in this proposed rule that came out Tuesday, July 14th, I think surprised us all.

So this G code really is just a, goes through what we call, I guess, the Medicare rules making process. So this CMS, you know, decided based on feedback and comments they received, in my opinion, from speech language pathologists that, you know, reached out either to CMS or reached out maybe to their representative or senator, et cetera, and then they said something to CMS.

So CMS came up with this, uh, G code. This goes through the, the Medicare rules making process. It's, you know, GSLPP. So basically GSLP and an extra P, and it's a HCPCS code. And basically this is now open for comment. I do agree with you, Jeanette. It really takes the place of 92507 because if you look at the descriptor, it's the treatment of speech, language, voice communication, auditory processing for pediatrics up to the age of [00:08:00] 21.

So those are the extra words that kind of got added in to that descriptor. You know, right now this is open for comment. Uh, so comments remain open on this whole proposed rule, the, the 10 new speech codes, the G code, and everything else un- until September 14th at 5:00 PM Eastern Time If this, you know, and CMS would take all the comments, and then they would make a decision, would they finalize what they proposed?

Would they modify what they proposed? Or would they, based on feedback, not, not do what they proposed? That final rule is due out on or around November 1 of 2026. November 1 is a Sunday, which means most likely it will come out either the Friday, October 30th or that early week of November 3rd, 4th, 5th. If CMS does finalize this G code, meaning it's going to exist come January 1 of 2027, it only mandatory applies to Medicare [00:09:00] patients.

You know, state Medicaid programs do not have to use GSLPP. Your commercial payers, Aetna, Cigna, Blue Cross, etc., were not even required to use GSLPP. Uh, they could, or they could use, you know, the, the 10 new codes that are coming out January 1 of 2027. So, you know, that's, you know, what people just mistake.

They think this automatically is going to apply to everybody, and it's not. Obviously, insurers can decide to use it. Insurers can also decide not to use it, which I think now because of this unknown can make it very hard now for SLPs in pediatrics to try to create their budget for 2027. I mean, obviously, we do know the monetary values of the 10 new codes for Medicare, what they're proposing.

We know the monetary value of this code, uh, if it does go through, uh, assuming the conversion factor is what it is [00:10:00] for next year, what they're proposing, and the RVUs don't change. So really, the, the G code, as proposed, will pay about the same amount of money as the 30 minute base code for speech sound production However, if you do speech sound production and language comprehension and expression, that combo code, that 30-minute base code actually will pay more than that G code.

And a- again, the unknown would be if this does get finalized, what will the payers do in your state? And then also, how will they value that G code? Because that G code under Medicare took a significant hit. So, you know, for 92507, this year the work RVU is 1.3. The practice expense RVU is 0.97. What CMS is proposing for 2027 for that new G code is still a 1.3 work [00:11:00] RVU.

Unfortunately, practice expense went down to 0.71. So the total RVU and the malpractice stayed the same at .01. So this year, 92507 total RVUs are 2.28. Next year for that G code, CMS is proposing 2.02. So kind of a, a long answer there. It sounds like, just to simplify everything that you said, that there was some devaluation with this new code, but there is actually some opportunity to make a little more money with the combo code.

So it, it's all dependent on what the insurances and Medicaid adopts and what's being treated. So we don't really have all the information to state something one way or another, but I think you didn't say this. Overall, if people are thinking about what's best for, for their practice, it's hard to make [00:12:00] that decision because we don't have all of the information yet because we don't know what company, insurance companies are going to do.

So it's hard to know. Nick, number one, you are correct on that. You don't know which code they may use, and then also you can run many different scenarios of course, but then you have to kind of, "Okay, here's what Medicare is proposing for payment. What percent is my Blue Cross gonna pay? What percent is my state Medicaid gonna pay?

What percent is United Healthcare gonna pay?" You're gonna have to try to figure that out. And I know Anna is, I'm sure, can give some input on this during the podcast as well. Rick, Emily, one of you might know this. Would it be safe to s- or I guess this is a Rick question. Would it be safe to say if people are trying to project, to take a look at the percentage of payments now, and would the insurance companies and Medicaid sort of follow what they're already doing?

So if 92507 is $75, what is the decrease [00:13:00] or increase, and could... Is it safe to just, remember, assume that they would probably follow suit with this new code? Yeah. So for example, let's say... And I'm gonna make math a little bit simpler for myself. Let's just say Medicare was paying s- $80 for 92507, you know, and your Blue Cross is gonna be paying $88.

Well, could you say that's 1.1 times Medicare? Now, whether Blue Cross intentionally did that or not, you know, that I don't know. If another insurance is paying, you know, only $70, does that mean they would pay maybe 88% of the Medicare physician fee schedule? So you're gonna try to do that, and maybe you can figure it out also on your Medicaid.

Um, I think payers that pay on a per visit rate, you know, where you just get a flat $70, $75 per visit, they may not change that payment because it's a per visit anyhow, so, uh, that may be a little bit [00:14:00] easier to budget if you have a big payer mix of that. I think the tougher one's gonna be that per CPT code one.

And then also, I think you have to look at, do you typically only treat a child for 20 to 30 minutes? In which case, you might like that G code, whereby if you say, "Well, Rick, I typically treat kids for 40 minutes," you might like the, the new code, the new codes because you get the 30-minute base code plus the add-on 15-minute code and definitely make more money than the G code that would be untimed Something that I didn't say at the top of the episode, I might even move this comment there.

If you own a business and you're making billing and coding decisions and you're responsible for finances, this is really something you need to pay attention to. Individual practitioners in pediatrics need to be aware of this and still need to jump in because this may affect your paycheck, right? So you need to be engaged.

This [00:15:00] is very important for business owners, but it's equally as important to be a, a part of this process because we all want raises, but, you know, you don't want a huge decrease in your pay because at the end of the day, especially in healthcare, and this is why I, I have concerns for skilled nursing facilities, if an employer takes a hit, it's not them that's gonna take the hit.

They're gonna transfer that hit to us via productivity or decrease in benefits or decrease in compensation. So it is still your responsibility to understand, and ultimately, your employer is gonna tell you what they want you to do based on their business, but you still should be a part of the process at this point because it's going to touch everyone in some way.

We just said Medicaids may adopt it, they may not. So it also impacts school SLPs that are billing Medicaid. So this is touching everybody. We've said that, I've said that since the [00:16:00] beginning. No one is exempt from this. We all have to be involved. I was just gonna piggyback off of what Rick said. From a business owner's perspective, talking about planning, what I did immediately when they came out is I looked at, okay- Which one is giving me the biggest decrease?

And the reason for that is exactly what you just said, is as a business owner, I have people that entrust me to create an environment and a paycheck, and the ability for them to be able to pay their bills and their, you know, mortgages, and I have given them a promise that I can sustain this. And so I make a lot of decisions right now that's way 5, 10 years in the, in the future.

I, I've already made decisions for this year, next year, and the following year, years ago. And so again, these are wrinkles that happen, obviously, with these new codes and, you know, whatever. But what I did is said, "Okay, how do I look at this as which one is the [00:17:00] lesser of the two evils?" Because they're...

neither one of them are gr- like, given a choice, I don't want either one. I, I don't, I would rather just stay with what we're doing. Like, we would all want that. That's the, that's the, that, that's what I want. But we have le- which one is the lesser of the two evils? And that is the kind of mindset that I went after.

It is, okay, let's figure out which one is most sustainable for me as a business owner, and if that means changing my operations a little bit, okay, so be it. Because guess what? That allows the people who are employed by PTP to continue to have a paycheck, and continue to possibly continue to still get a raise every year.

We still, we do raises every year, and so that is my goal always is putting my employees first in the sense of how can I create a sustainable business and how can I, even if it is a decrease, which one is going to impact my business the least? And so that is the mindset I took. It kind of is a reverse of which one pays more.

It's which... 'Cause at the end of the day, we all know what this was [00:18:00] about. This was not about let's give SLPs a raise. OTPT, they already know. They, they've been through this years ago. We haven't. We've been very lucky, but that's what this is about. They, there are budgets. They're trying to save money.

There's a lot of budgetary things going on in the, in the government at this time. So I know what this is about. It's just which way is gonna impact you the least, and I think if you think about it that way, 'cause it's gonna happen. It's gonna impact you. It's, it's gonna be painful neither way. However, which one is going to impact you the least from a reimbursement revenue standpoint?

And I think that is such a good mindset to have so that you can really look at it from that perspective so that your employees aren't affected as much either, not only your business, but also your employees. Yeah, just to add, I agree with Ronald. I think you really have to look at it from your perspective, your practice, and what's best for you.

Um, you know, right now, based on all the proposals and the proposed payment [00:19:00] amount next year for Medicare, if you look at that G code, you're looking at about sixty-six thousand and thirty-four cents on a national average. And that's whether you do twenty minutes, thirty minutes, forty minutes, fifty minutes.

That's... It's an untimed code. Where if you look at that speech sound production code for thirty minutes, which you gotta do just sixteen to get the bill to thirty, that's sixty-six oh one. But if you say, "Rick, I usually treat my kids for forty minutes," where you get that add-on code, you're now up to ninety dollars compared to sixty-six thirty-four.

You do that speech sound language comprehension code by itself for thirty minutes, that I think is like over, just over seventy-one dollars. Do the add-on code, you're at ninety-nine dollars and fifty cents for thirty minutes. So a-again, um, you might want the ten new codes if you say, "Well, we always do the forty minutes."

But if your state-- if this G code goes, and your state Medicaid adopts it, your other payers adopt it for pediatrics, [00:20:00] well, you're at sixty-six thirty-four on, on the Medicare side and whatever it may be for your, your payers Right. So when thinking about the adoption of these codes, specifically for pediatrics, this isn't an adult thing.

The adults are not included in this G code, but don't, don't tune out because you still have to comment on this. Is this an either/or situation, an either/and? I- if an insurance company or a Medicaid adopts the G code, is... Do we think the timed codes are still an option, or is it they're gonna do both? Like, how do we see that playing out?

Well, I think when you look at Medicaid, you know, most Medic- state Medicaid only covers, you know, therapy for patients up to age 21. So obviously there, that would be the G code. Now, if there are some states that still have benefits for PT, for [00:21:00] speech, you know, above 21, uh, you know, they're gonna use the new codes in my opinion.

When you look at an Aetna, Cigna, uh, you know, your Blue Cross, they're gonna have to use, if they adopt a G code, they're gonna have to, they'll be using both because they'll use a G code for patients up to age 21. They'll use the other 10 codes for, you know, 21 and over for the adults in geriatrics. So that answered my question.

It isn't for pediatrics. If they adopt the G code, it's not SLP pick your path. It's not, "We're Aetna, we adopted the G code for pediatrics, but also we have the time codes for pediatrics." It would just be the G code and nothing else. Correct? I would fall off my chair if a payer adopts the G codes and says we gotta use that for up to age 21.

Th- they're gonna have to adopt the other 10 codes, the codes for the adults. Right. If they adopt, do the G code, I think it's the G [00:22:00] code for pediatrics, and they'll base the payment based on the age of the patient, you know, on the claim form, date of birth and all of that would tell you which code you should bill I know we don't have a, a ton of examples or none.

We have no examples really of this happening with PT or OT. So it's, again, this is all speculation The only thing that really did happen back in, I think, 2003, the CPT code 97014, which is unattended e-stim. And back in, I think it was '03, CMS created three G codes, G0281, G0282, and G0283. And, and the 28, the 0281, 0282 were e-stim for wound care, and the G0283 was, you know, e-stim for other than wound care.

You know, sort of like a TENS, uh, high volt galvanic, Russian stim, that kind of stuff. And they did that because they wanted [00:23:00] to track why PTs and OTs were using e-stim. Now, most payers in '03 onward stayed with 97014. They did not adopt G0283. However, UnitedHealthcare was one that did. You know, UnitedHealthcare did adopt G0283 for PTs and OTs in private practice.

So we've, we've, we've seen it in terms of, okay, Medic- you know, Medicare, we use G0283 for unattended e-stim. Most other payers, 97014. Could use the same logic, GSLPP for pediatric speech, and then the other 10 codes for 21 and over. You answered what I was gonna ask. Do we foresee

Payers adopting this across the board. Do we think they'll all do it? So you just gave the example of what happened. Emily, I wanna ask you as a business owner, again, and if, if [00:24:00] anyone hasn't caught on, we're not telling you which, which is better today. Definitely not. We do have some, I will have some suggestions at the end, which include, if you don't listen to the end, I'll say now, you might wanna continue to wait as we potentially gain more information.

But again, we're working with what we have right now. Emily, as a business owner, do you see some problems if one payer takes a G code and another payer goes with, with the 10 codes? What are some potential downsides of giving payers the option to choose the time codes or the G code, and how that might, uh, impact billing practices in your business?

Most EMRs are set up where, you know, there's a flow of things. And so my concern with having options from an, an EMR and a workflow s- standpoint is that you're going to have to remember [00:25:00] who is applying or who is adopting which set of codes. So you're going to have Blue Cross that's gonna potentially adopt the time codes.

You're gonna... 'Cause, like, just because the G code goes through, I mean, I just wanna vehemently say this, and please somebody, Rick, tell me if I'm wrong. G code goes through, let's say, that does not mean that Blue Cross has to adopt it. And Rick said that, but I wanna say it again very clearly that there is a very good potential that Blue Cross...

Um, this is, this is an example. Blue Cross decides they are gonna go with the time codes because it's easier because they have to do adult MPES. And then UHC, well, they're a flat rate payer, they don't matter. And then you have the Medicaids. They decide they go with G because you know what? All we do is 0 to 21 anyway.

And so just those two as examples between Medicaid and Blue Cross, both of those are, I'm gonna use those examples throughout my spiel here. You have EMR. You have to set up different back-end back office, especially if you don't have a very, a [00:26:00] sophisticated, highly advanced EMR, you're going to have to set this up on the back end of your EMR that these type of codes go with these payers and only this one.

The other issue is, if you think about it, you got timed codes. Okay, timed codes, okay, you're gonna have to do, in my opinion, 32 minutes of therapy or 38 minutes of therapy, you know, to make that worth it. Well, if you got a G code competing with that it, it starts to become a, a, it's gonna hurt you in reimbursement because then how in the world do you schedule 32, 38, 30 minutes?

Because your G-code is most profitable at 30 minutes or less, okay? Your timed codes, I've done the math, and we can get into this on another podcast, are most profitable at 40 minutes. How in the world, if you have these competing codes, you got timed versus untimed, that different payers are going to adopt, and that is, I b- truly believe that's gonna happen.

If this G-code goes [00:27:00] through, you're gonna have different payers adopt different ones. Then how in the world do you schedule a 30 minute for the G-code and a 32 to 38 for your timed codes? And not only that, but then how do you make... If you don't do that, then how do you make it profitable? Like, you start to cut into your profits to go, "Oh, gosh.

Well, these percentage of patients are G-codes, and these percentage of patients are timed." Do you... You kind of are starting to see the problems that are going on in my head going, "This is an operational nightmare from the standpoint of giving payers the option to choose." I don't want to give payers any options.

I want to give them the least amount of options. I am not on their side ever, so I don't wanna give them very many options. That's just my personal opinion. So then when you get into the operations of, you know, the billing and the scheduling, I'm not sure a lot of people have thought about that. And so you really gotta think through your org board or however you have your business set up, and how does this code affect my schedule?

[00:28:00] Is this G-code gonna be an option for payers? That is the question we have right now. I think the shortsightedness of this is, "Oh, G-code, that replaces 92507. We operate the same." It's not that simple. And I had thought the same thing when I saw it come out, and then I saw the payment of it and I was like, "Okay, that's...

no." But I was like, "Oh, okay. Maybe we can operate the same." 'Cause again, I want neither one of these. I'm gonna stay with 92507. But I think you have to be very careful in realizing adding this G-code, what that truly is and what impact that has. It's not just, oh, it's a replacement for 92507, let's go and march forward, because that is not the case.

Because payers have options, your schedule is impacted, your revenue is gonna be impacted, and so that is just, it's so important to do the math. But you know what? It's worth it when you can make it work, when you can realize that there's not as much of a decrease as you thought if you just change your operation a little bit.

Uh, it's just really important to really think [00:29:00] about every single department in your company, not just, oh, this just matches 92507 and let's march on, 'cause it's not that simple. I think what I've heard Rick say and what I'm hearing and I think understanding, so trying to simplify this for our listeners, basic thir- 20, 30 minutes, the G-code might be better.

You want that to go through, cool. But Rick, I imagine also that even if they all do adopt it, if there is that scenario, they're not all gonna roll out at the same time on January 1. I imagine some Medicaids will be ready to go, others will take longer. Pr- uh, private insurances might not, might wait three months.

What, is that a safe assumption? Well, that, that's a very good assumption. You know, it w- it was, I mean, I, I had been preaching even before the proposed rule came out, the surprise G-code that, you know, once the rule came out, you know, we knew the 10 codes were coming. I was telling [00:30:00] people, "When once this hits, this comes out, start contacting insurers.

Make them aware of these codes, the descriptors. You're gonna see the RVU proposed payment from Medicare." I was telling you to s- I was gonna tell you to start July 14th, 15th. Well, now you got this G-code. W- well, you would... It's gonna be difficult to now go to your state Medicaid, to Blue Cross to Aetna, and tell them, "Get ready for the codes," because, well, you know the 10 codes are coming.

You can still do that, but you can't say much about the G-code because you don't know if it's gonna come or not come. And I guess if you're gonna under the assumption that you think CMS is gonna finalize it and you wanna take a chance and do that, you can, but if not, you know, this rule now comes out November 3rd, November 4th in there somewhere.

Man, you got Thanksgiving, you've got the holidays. You know, Medicaid's slow anyhow in a lot of states. You know, you have some private payers behind, and I can... And kn- I know Emily mentioned at the start, being a PT, [00:31:00] we've gone through this year after year after year for my entire career. I can tell you when we have new codes come out, especially when we had the new eval codes come out back in 2017, there were some payers in February and March didn't have those new eval codes ready.

So could this be an issue? Absolutely. Do I expect it to be an issue? And I'll speak for Emily, I think we both expect it to be an issue with s- with some commercial payers and some state Medicaids So let's talk about some of the panic I caused with the 60-minute concern with the G code. There's a category.

So the category is it's untimed, but every code has a rule, and so the rule states, it does state, we can read it, that it's an average of around 50 to 60 minutes. Fifty-minute face-to-face, five minutes post, five minutes prep for, you know, non-face-to-face. And I think what I said understandably scared people that, you know, if you weren't treating that it-- your reimbursement could be cut in half.

So [00:32:00] again, my apologies. But let's unpack that a little bit because right now everyone on the internet, "Well, nine two five oh seven has been that and it hasn't been an issue." Do we think it could be an issue now? And if so, why and how? Or do you think people are okay to go ahead and continue to treat twenty to thirty minutes without issue?

So a-again, every CPT code is comprised of, you know, three relative value units, one of them being a work RVU. Within that work RVU, there's a pre-service time, intra-service time, and a post-service time. And nine two five oh seven has always been for many, many years, five minutes pre-service, fifty minutes intra-service, meaning face-to-face treatment, five minutes post.

So kindly the, the work RVU is kind of based on sixty minutes of, quote, time. Now, just because it's based on sixty minutes of time as an untimed code does not mean from a billing [00:33:00] perspective you have to do sixty minutes. It is untimed. So obviously, could practices, you know, could this new G code go through?

You know, it's based on the five pre, the fifty face-to-face, the five post, sixty-six dollars thirty-four cents next year right now, national payment amount. That can change of course, but that's what I'm going by. Could you for the next three years do all your pediatric patients for twenty, thirty minutes, bill this G code, get paid the full amount, everything be fine?

Absolutely. I mean, obviously many SLP practices have been doing it for years and years with nine two five oh seven. Now, with that being said Could something happen where Blue Cross of Louisiana decides to, not that Emily would do this, but, you know, they audit Emily's charts, and they pull 50 speech therapy charts, and each have 20 visits in it, so 1,000 visits.

In all 1,000 visits, the note says they saw the child for 30 [00:34:00] minutes, and Blue Cross Blue Shield of Louisiana has been basing the payment on 60 minutes. Now, can they deny Emily? No, it's an untimed code. But if they... Now they go audit other speech therapy practices in Louisiana, and they see that same pattern, could Blue Cross of Louisiana decide, "You know what?

We can't deny. It's an untimed code." But could they maybe decide to change the work RVU for that code? So instead of it being 1.80, you know, could they say, "Well, gee, they're only spending 30 minutes. You know, we'll make it 0.9," which then obviously would reduce the payment. Could that happen? It could. Have I seen it happen yet because of that?

No. Lot of what-ifs. You just jogged my memory with something that did happen with Blue Cross. All of a sudden in 2024, Blue Cross stopped paying for, uh, swallowing, feeding and swallowing, for, um, speech therapists [00:35:00] in Blue Cross Blue Shield of Louisiana. All my Louisiana therapists, about, there's about six of us that are in a group text, and we tried to fight this.

And I went round and round with that medical director, and he stopped paying for it because he found that nuance of the 60 minutes, and I sent a bunch of notes to him. And he said, "But you're doing 30 minutes." And I was like, "Right. We're very efficient," which I stand by. We are very efficient. And he was like, "Okay.

Well, that's great, but I can't dock your pay because you're doing 30 minutes, but I'm bundling your 92507 and your 92526 that's feeding," and he bundled it, and they did not budge. I fought and fought and fought for probably six months. I sent information. I sent data. So it didn't affect the RVU. However, what it did do is they said, "Well, this is an untimed code."

Feeding is also untimed, so just so we can clear that up. But what they did is they s- he said, "I cannot," and it was, this is almost a [00:36:00] direct quote, "I cannot justify paying both codes when the amount of time in front of the patient is 30 minutes. I cannot justify paying two untimed codes." And- I, at the time, was like, you know, obviously fuming and mad, because I didn't even know anything about this 60 minute...

You know, he had found it, and it, it was kind of buried in CM. I mean, he went deep into some stuff, and he found it. And honestly, like, that's where you're gonna see the impact. They're gonna find ways with untimed codes to start bundling, I think, in my opinion, that they're gonna continue to do this.

They're gonna continue to find ways to take these untimed codes and bundle them and say, "We cannot justify this because when you provide us notes, you're doing 30 or 45 minutes or whatever, so we're gonna bundle these." And they can... And what Blue Cross told me is, "We can do what we want, because we're a private entity."

And I was like, "Okay, I have zero argument with that." And they can. So it's just, again, if you [00:37:00] take a lot of Blue Cross, I think it's something to think about. Rick, you tell me if I'm wrong. Timed codes, there's no bundling of them, right? That's not a thing? Like, they don't bundle. It's untimed. There, there are some codes that cannot be paid the same day when done with another code, so that does happen sometimes.

But, um, you know, but, like, when you look at, say, therapeutic exercise, neuromuscular education, therapeutic activity manual therapy, we can do all those codes on the same day for just about all the payers and be paid for all those codes I can give an example especially for our adult listeners. One of those examples of not billing together would be a modified barium swallow study cannot be billed the same day as a barium swallow study with a GI doctor, right?

So those are two codes that can't be billed in the same day, and those come from edits, the NCCI edits. And those aren't out yet either, which will place more rules probably maybe on our timed [00:38:00] codes. So we don't even have all of the information yet on the timed codes of what can and can't be billed together.

Now, our friends over at ASHA have said to us directly that they don't anticipate the feeding and swallowing dysphagia code to be impacted anywhere, that it, it still is untimed, and it, for adults, it can still be used with these timed codes. So that is a benefit there that we'll talk about in a future podcast.

But for pediatrics with the timed codes, that is a benefit where it would be an add-on if they're paying for it, it, and a way to generate more revenue. It's something to think about. With untimed codes, it is starting to become an issue, at least in my state. Our Medicaids bundle a ton of these un- untimed codes, so we are not getting credit, reimbursed, whatever you wanna say.

Um, there's two, one or two Medicaids that do not pay feeding for speech therapy. So they'll do, you know, 92507 and 92526, [00:39:00] which is feeding. It's bundled as 92507. So it's just, again, it's something to think about that the states are doing it with Medicaids. My Blue Cross is doing it. If your Blue Cross is doing it, it's something to think about.

I, in my opinion, don't think they're gonna just unbundle it because there's now a G code. Um, so it's just, again, it's something to think about. It's something to think about if you do a lot of feeding because if you do a lot of feeding and you have timed codes I know w- this wasn't a podcast on the feeding, but I'm just giving everybody something to think about that if your payers are bundling your speech and your feeding codes together, all of a sudden it gets unbundled when there's timed codes.

So just, it's just, again, something to think about when you're really reflecting on how your practice operates and, and what are you not getting reimbursed for now. There's a really good chance that you will in the future. Yes. Great, great points. Stuff to think about there. And the NC set edits will come out right around December 1, uh, going into effect on January [00:40:00] 1 of 2027.

Yeah, a one-month notice? Yep. From a clinician's perspective, something I've learned over the last week, 'cause I'm a business owner, but I don't bill these codes. I bill f- the nursing homes directly, and the only code I interact with is the CPT code for fees. So I guess I didn't understand, when pediatric companies are putting in for their reimbursement, they are not submitting times.

So the way that these insurance companies will collect the data is through that audit that Rick mentioned. So the way that any data or information would come would be, "We're auditing you, we're looking at the charts, and now we're seeing how much time has been given." So it's not like we're feeding these insurance companies or Medicaid a ton of data with our notes, but there c- And we, this is something that we've said, too, even with the timed codes, we're putting ourself at risk for audits in that SLPs will have to change how they document [00:41:00] for these timed codes because they're gonna be looking for errors and mistakes.

But same thing with the G code now. They're gonna, if they're auditing, they could be looking at the time. So there has been a lot of information pushed out online to SLPs over the last week or so since these have come out. One thought process out there is, or I guess two, we need to work on the value But also we need to reallocate the intensity of what we're doing.

We, we need to reallocate the spread of face-to-face versus training parents and training caregivers. Is that possible, Rick? How do we go about communicating that to CMS if it's something we wanna touch on in a comment? Yes, I think what you're asking, is it possible to reallocate and just using the new G code, the, the five minutes of pre, the 15 minute of intra, and the five minute of post.

Is it possible? [00:42:00] Sure, I can't say it's not possible. Do I think it's realistic? I, I don't. I mean, 92507's been that way for years. Uh, you know, the 10 new codes went through the RUC process and I think... and I can't recall which ones exactly, but I remember going through the RUC process where these codes get their RVU values.

Uh, I remember at that time, uh, there was some more minutes on the pre and the post on the new codes compared to the face-to-face time, and the RUC committee took away the minutes of the pre and the post. They decreased those minutes and had the face-to-face, I think, be 30 minutes face-to-face. So that kind of already went through that process, and then CMS is proposing to accept the RUC recommendations.

So basically you'd have to go back to what was originally proposed to the RUC and the pre-service time and the post-service time and, and try to argue why those minutes are correct in that, and then why to [00:43:00] decrease the, the face-to-face time. But again, I would say the G code is untimed. Okay? So from a billing perspective, technically speaking, 30 minutes you can bill the code.

Technically speaking, 15 minutes you can bill the code. You know, obviously just upon audit, are you possibly at risk if you continue seeing, seeing people for 15, 20, 25 minutes? If the insurer feels you did not do everything included within the code, you didn't maybe, you know, you didn't meet the needs of the child, uh, you were doing it from your own, you know, perspective to make money.

You know, it's just that risk. But is it possible? Yes. Do I think it's gonna be successful? In my opinion, only, no. I think what I wanna start to wrap up with is increasing value. Is it possible in our comments to CMS to try to get them to increase the value? Have you seen that happen before where value has increased after a comment period?

Is, [00:44:00] is it possible? And, and what might we wanna speak to if, if we want... 'Cause I think we all need to address value. Value is a problem across the board. We need to be paid more How do we do that effectively, if- Yeah ... if at all? You know, and again, unfortunately, under the Medicare Physician Fee Schedule, we have this thing called budget neutrality.

So when some CPT codes get an increase in RVUs, other CPT codes have had a decrease in RVUs, uh, because it, they can only go up so much in a percentage from one year to the next. So obviously now the downside for speech is, you know, all the speech codes took a hit this year. Uh, where last year, for, for this year in 2026, all the speech codes saw an increase in payment, the PT, OT codes all went down in payment, uh, in 20- 2026.

In 2027 it's the opposite way. PT, OT codes saw, [00:45:00] you know, the RVUs on some of these codes go up .02, .03, where the speech codes went down. So now it's like going back to argue, uh, especially I think on the speech sound production base code and the add-on code and the speech sound production language comprehension expression combo code and the add-on code, I think those are the two codes you try to make an argument on the practice expense side because, you know, I, I know when I s- saw it coming out of the RUC, you know, that PE dollar amount was significantly higher for those codes compared to 92507.

But then as we go through that complicated CMS process, the formula percentages and all of that, that's how it kind of spits out the PE RVUs for those codes. So I know it's gonna be a tough one for your followers to maybe handle, but this may be one you have to talk to somebody at ASHA to see what's the best way to formulate comments on the [00:46:00] PE RVUs for perhaps some of the, the base codes and the add-on codes.

What argument could we make to try to get an increase in those RVUs that would then increase the overall payment? And what exactly is included in the practice expense? So the practice expense is really the cost to run a practice. So this would be your support personnel, like your front office person, your billing person, uh, the rent, mortgage, supplies, equipment, utilities, internet, things like that.

Where the cost of a speech-language pathologist, that's in the work RVU. That's his or her, you know, mental effort, judgment, stress, knowledge, intensity to provide the service No, I was just gonna say about the allocation is if you listen to what Rick is saying is he didn't say, "No, it's impossible", but he did say, based on him [00:47:00] doing this for over 20 years, and I take that as, you know, I take that as expert opinion, if you're gonna call it like in a court case, essentially.

But I think it's important to recognize that none of us have been through this. None of us have paid attention. I have not been an SLP for that long. However, I'm sure the ones who have, have not really paid attention to this process. And so I think it's important to listen to the people who have been through this, who understand the trends of AMA and CMS better than the average, you know, provider or clinician.

And I think it's really important to, to listen to that, but it's also really important to go, "Okay, I'm listening to that, and then how does that, you know, again, bounce off of how I practice or how I operate my business or how I am as an employee?" I think it's all super important to go, okay, if the allocation, he's saying, you know, them...

basically if we reallocate all of this, it sounds to me that we've gotta go back through a process, and that's not something that he [00:48:00] created or I created, it's something that CMS and AMA has created and it's been there. It's not... SLPs aren't gonna shake that up and decide, "Oh, we're special and we get to just skip steps one through three."

There's a lot of very, very systematized processes that have been on- ongoing and have been established for years. And so there's just an awareness of that and, and a recognizing that, hey, this is the way this goes. I don't like it either, I promise you. I'm, it, it was way over my head for most of this stuff.

But recognizing that, okay, there is a process for a reason, and if we go and ask for something like this allocation, like, hey, we want different, you know, we want the face-to-face to be reduced and all of this. Okay, if we ask for that, why Rick's probably saying that it's, it's not gonna happen is because of the actual fact that we have to go back through a process for that.

So when you understand the basis of why he's saying that, you kinda go, "Okay, well I don't know if we want to ask for [00:49:00] that, if that makes sense. Um, and if it doesn't make sense to ask for that, then I don't want to, I don't want us to spend our time and energy going that route because it's just going to be a hard no.

It seems like because of the fact that we'd have to go back through a process. So I just, again, want to point out that it's important to make sure you go to the experts in the field, but also bounce that off of kind of common sense and going back to how is this process supposed to be and how has this process always been?

Because it's not going to change because SLPs decided to get into the mix, unfortunately. For every 0.01 RVU you can try to get a CPT code increased by, it adds about roughly 32, 33 cents to that CPT code. So when you look at, you know, just to kind of give you an example here, your 92X2X, which is your 30-minute speech sound production, the [00:50:00] PE RVU for that is 1.10.

When you look at the base for this language comprehension expression, 92X4X, the PE is 0.51. Now, when you look at that combo, speech sound production and language comprehension expression, I know people are thinking, well, we should just add 1.10 plus 0.51, have it come out to 1.61. For that code, the PE is only 1.17, which was significantly lower than we all thought.

So do I think that could be, you know, a code? You know, again, you're going to have to probably work with somebody at ASHA, you know, that went through this process or somebody, you know, SLP on the RUC committee that understood how this all went through and the dollar amount that was assigned to it for direct input and all that.

But what if you could get that from 1.17 to 1.2? That could be an extra dollar. Can you get to 1.21? Could it be an [00:51:00] extra $1.33, you know, for that base code? And then some of that would maybe then add on to the add-on code, perhaps. So again, not saying it can't be done, but you're going to have to do some work.

And again, no offense, no one's experts probably watch this podcast on this. So you're going to have to, you know, use ASHA or somebody else to help you formulate those letters. So speaking of ASHA, in their webinar, which I was not able to attend but have been briefed on many times, um, they mentioned that there was an interested party that got what they wanted, and referring to this movement and all of us.

To be clear, this is not what we asked for. This is not what we were fighting for. We were not fighting for this G code and these options and a devaluation. So just to put that out there, ASHA, that's not what we were asking for. And didn't I say ASHA is setting the [00:52:00] stage to blame this on FixSLP, me, us, whatever?

Didn't I say they were setting the stage? And, and what did they do? So ASHA has stated publicly in their webinar that this is not the direction that SLP should be going, and they will be fighting the G code with CMS. This is my opinion and my opinion only, but they came out with that thought pretty quickly.

There is not one person on the HCEC committee who understood anything more than Rick or anyone else. Okay? They, they're not fairies that have all of this additional information that no one else knows. It is my belief that they came out with that statement for self-preservation. They haven't taken a look at is this G code actually better for private practices in clinics in pediatrics versus the 10 [00:53:00] codes.

They didn't take time to consider that at all because they came out with that statement pretty quick. And they're not listening to their constituents either because there are people saying, "This could be better for us." ASHA is always going to self-preserve. They have been showing this to us for years, and especially through this process.

They have lost control of this narrative with this G code that surprised them as much a- as it has surprised us. So just remember that because they're saying they're gonna fight it doesn't mean it's better or worse. I'd take their, their stance with a grain of salt. Like Rick said, do some work. Think about this.

Think about what's best for your practice. If you are an employee of someone, maybe talk to the business owner and say, "How can we support this? Because I wanna, you know, I wanna [00:54:00] continue with the package I have. What are you seeing in the work you're doing?" If you are a business owner, you can join AAPPSPA.

That is for business owners only. You can also take a course from Rick. Rick, while not an SLP, has been in the billing and coding space for many years across different practices and sees the patterns, like Emily said. There is a course that he is having that is, if I drop this when I hope to, the course will have already happened.

So Rick, can people go back and buy the recording? Is that gonna be an option, or will you have another date available? How's that gonna work if people have listened today and want more educ- Yeah. Thank you. Uh, it'll be on my website, which is gawendaseminars.com, so G-A-W-E-N-D-A seminars, gawendaseminars.com, and you [00:55:00] can put your cursor over the word courses.

It'll have a dropdown menu. You can click on demand, and then you'll see the webinar there. Just scroll down to your first look at the 2027, uh, new therapy codes. So I'll, I'll say, uh, this will be, uh, probably about a two-hour webinar where I'll go through the 10 codes, go through the G code, go through all the RVU values, payment, possible NCCI edits, documentation tips.

We'll talk about MPPR, the multiple procedure payment reduction policy, and how that may or may not impact what you get paid. And we're gonna talk about, you know, how much time you must do with a 30-minute code, how much with a 15-minute code, and we're gonna do six billing scenarios. Well, I'll tell you, "Here's what you did and here's the correct answer if you're using the new codes.

Here's the correct answer if you're using the G code." And Emily was kind enough to, you know, give her input on the six as well, so we feel pretty good about the six we put together. And I got to see them. They're a bang-up job. They're great. [00:56:00] I won't be there live, but I will be watching the playback. Rick, just for our SLPs, do your courses offer ASHA approved CEUs?

No, unfortunately, because I do so many webinars and some of them spur of the moment, I just don't have the time. Do you give a, a certificate of attendance? Yes. Everyone listening can print out a certificate of attendance, uh, that, you know, ASHA may or may not accept for CEUs or your state may or may not accept, but it does have the, the course title on it, my name, the date, and all that.

Because Rick is not familiar with FixSLP before the 92507 debacle, he doesn't know that we've already educated all of you that you do not need ASHA approved CEUs a lot of the time. If you're unsure about what your state does, don't forget, or if you're new to FixSLP, you can head to our website, fixslp.com.

I have a very [00:57:00] chaotic state map because it is the Wild Wild West. It is color-coded. But remember, friends, even ASHA doesn't require ASHA approved CEUs. And remember, ASHA CEs are made up by ASHA as a way to take your money. Those happen when you pay for their tracker. Our friends at Speech Therapy PD, as a result of this movement, have m- built out their tracker and have made it free to everyone so you can upload your certificate in less than two minutes.

I always time myself because I like to give the truth here as much as possible. In less than two minutes, you can take that e-certificate from Rick, put it on Speech Therapy PD- And it's there. You can print a transcript if you need it. You're set to go. Okay? There are several states that you have to take their state-approved or the ASHA-approved.

That's not the [00:58:00] majority. So if you're not sure, look at our map. Okay? So everyone can get, we call this PDH, professional development hours. Everyone can get PDH. So and it's not just for business owners, right, Rick? Anybody can take this for a full understanding, and they should walk away knowing what, what you've said.

This can be an SLP, a biller, your office manager, your administrator, anybody can listen to this webinar. I would highly recommend billers take it, not just your clinic directors or your, you know, your business owners. I think it's, it, uh, we have, we had at least three or four courses that we, um, had had in the past, and our billers very much said that it was very helpful.

Yeah. And again, we all need to understand this. Your employer will tell you what they want, but you still need to have an understanding of what's going on because it's changing. It's changing. Okay, and just to be clear and transparent, this was not a paid sponsored ad. Rick has not asked us. We are [00:59:00] saying this because I am not the expert.

Emily's not the expert. Our private pr- business owners could go to APSPA, but there are also a lot of other SLPs out there. And y'all saw what ASHA gave you. Okay? So Emily and I may be back next week. Uh, we have some adult things to talk about. I have concerns I need to put pen to paper to really work out my concerns and maybe then check with Rick to make sure that I'm on the right track.

All right, everybody. I'm sweating in this business office here at the Hampton Inn in our nation's capital. So I'm gonna say thanks for fixing it, and we'll see you next week. Thanks for listening to the FixSLP podcast, the podcast shaking up the field of speech-language pathology. Don't forget to check out our social media or fixslp.com for our latest promo codes for continuing education, therapy materials, merch, and more.

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