Abstract:
This Local Coverage Determination (LCD) describes the coverage and limits of coverage for speech and language pathology therapy services when billed to either the Medicare Part A or Part B. This LCD shall not be construed to expand coverage to services defined as non-covered by National Coverage Determinations (NCDs).
Definitions:
Rehabilitative therapy includes services designed to address recovery or improvement in function and, when possible, restoration to a previous level of health and well-being. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2(C)) and 220.3
MAINTENANCE PROGRAM (MP) means a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220 (A))
Indications:
Speech-language pathology services may be considered reasonable and necessary when the criteria in this LCD, as well as the National Coverage provisions listed in the related Billing and Coding Article, are met. (Please refer the Billing and Coding Article A52866)
Evaluation of Language Disorders:
The order or referral for the evaluation and any specific testing in areas of concern should be designated by the referring physician in consultation with an SLP. The physician's certification of the need for care (e.g., approval of the plan of care) may substitute for the order. The documentation of the evaluation or re-evaluation by the SLP should demonstrate that an actual hands-on assessment occurred to support the medical necessity for reimbursement of the evaluation or re-evaluation. The documentation should differentiate between evaluation or re-evaluation and screening. Screening assessments are noncovered and should not be billed. The initial screening assessments of patients or regular routine reassessments of patients are not covered. Evaluations in the absence of signs and symptoms are not covered.
The evaluation should include the beneficiary's history and the onset or exacerbation date of the current disorder. The history in conjunction with the current symptoms must establish support for additional treatment. Prior level of functioning should be documented, as well as current baseline abilities, to establish the basis for the therapeutic interventions. Evaluations must include the plan, goals (realistic, long-term, functional, communication goals) duration of therapy, frequency of therapy, and definition of the type of service. Diagnostic and assessment testing services to ascertain the type, causal factor(s) and severity of speech and language disorders, should be identified during the evaluation.
For information on Re-evaluations please refer to the related Billing and Coding Article.
Documentation is expected to support the ability of the beneficiary to learn and retain instruction. Absence of such documentation may result in a denial of services. If the patient has questionable cognitive skills, a brief cognitive-communication assessment should be performed in order to establish the patient's learning ability. The brief cognitive assessment may also determine the need for more comprehensive cognitive performance testing.
For additional information on Medicare requirements for PT, OT, and Speech-Language Pathology evaluation and re-evaluation of services see CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.
Skilled Procedures and Modalities:
Skilled procedures include:
- Design of a treatment program addressing the beneficiary's disorder. Continued assessment and analysis during the implementation of the services is expected at regular intervals.
- Establishment of compensatory skills for communication (e.g., air injection techniques or word finding strategies).
- Establishment of a hierarchy of speech-language tasks and cueing hat directs a beneficiary toward communication goals.
- Analysis of actual progress toward goals.
- Establishment of treatment goals specific to speech dysfunction and designed to specifically address each problem identified in initial assessment.
- The selection and initial training of a device for augmentative or alternative communication systems.
- Patient and family training to augment restorative treatment or to establish a maintenance program. Education of staff and family must begin at the time of evaluation.
Documentation is expected to support the ability of the beneficiary to learn and retain instruction. Absence of such documentation may result in a denial of services. If the patient has questionable cognitive skills, a brief cognitive-communication assessment should be performed in order to establish the patient's learning ability. The brief cognitive assessment may also determine the need for more comprehensive cognitive performance testing.
Aural Rehabilitation:
Coverage for speech reading is only allowed with documentation that supports a loss of hearing sensitivity that cannot be corrected with a hearing aid or amplification. Documentation should also support visual acuity of the beneficiary sufficient to participate in aural rehabilitation.
Speech reading is considered medically necessary when determined by a licensed audiologist that the use of a hearing aid or other amplification would not significantly improve the beneficiary's understanding of speech. Speech reading training is not medically necessary for beneficiaries who refuse to wear a hearing aid. Routine screening for hearing acuity or evaluations aimed at the use of hearing aids is not a covered service.
Determination of the medical necessity for the speech reading will be based on the following criteria:
- Documentation of basic hearing evaluation and audiogram;
- Documentation identifying type and extent of hearing loss;
- Documentation of adequate cognitive and memory skills;
- Documentation that visual acuity, with glasses if applicable, is sufficient to allow the beneficiary to participate in the therapy;
- Documentation of the beneficiary's motivation to participate in therapy in order to improve understanding of speech.
See CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230.3.D.3 and the related Billing and Coding Article for more information on aural rehabilitation.
Group Therapy:
Group therapy sessions must meet the individualized plan of treatment requirement and are not subject to reimbursement if these criteria are not met. Group therapy coverage for speech reading can be covered (if medically justified) if the following criteria are met:
- Services are rendered under an individualized plan of care
- The group has no more than four group members
- Group therapy does not represent the entire plan of treatment
Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy
This procedure may be used for assessing voice production and vocal function. It may be performed by qualified speech-language pathologists.
Speech-language pathologists should have evidence that they meet the ASHA (American Speech-Language—Hearing Association) training requirements as outlined in the ASHA's Training Guidelines for Laryngeal Videoscopy/Stroboscopy.
Limitations:
Following are some examples of interventions which would generally be considered non-skilled and therefore not covered under Medicare:
- Non-diagnostic, non-therapeutic, routine, repetitive and reinforcing procedures (e.g., the practicing of word drills without skilled feedback).
- Procedures which are repetitive and/or that reinforce previously learned material which the beneficiary, staff or family may be instructed to repeat.
- Procedures which may be effectively carried out with the beneficiary by any non-professional (family or restorative aide) after instruction is completed.
- Services rendered by a SLP assistant or aide.
- Provision of practice for use of augmentative or alternative communication systems after being taught their use.
- Although speech-language pathologists may perform laryngoscopy for the assessment of voice production and vocal function, laryngoscopy for medical diagnostic purposes must be performed by a physician.
Generally, group therapy sessions, except as specified above, are not covered. Group therapy sessions in social organizations such as the stroke club or lost cord club are not covered. See the "Indications" section above for information on when group therapy might be covered.
Speech-language pathology services provided for chronic disorders of memory and orientation are covered services when significant functional progress is demonstrated at early stages of the disorder. When functional progress plateaus, the development of a maintenance program, including training of caregivers and family members is covered.
Preparation of memory aids such as memory books, memory boards, or communication books may be covered. Supervision of the use of such aids is not covered as these services do not require the skills of a qualified therapist.
All SLP services provided by anyone other than an SLP who is licensed or otherwise authorized by the State in which they practice, including a speech-language pathology assistant or aide, are not covered.
The following disorders are typically non-covered for the geriatric Medicare beneficiary:
- Fluency disorder
- Conceptual handicap
- Dysprosody
- Stuttering and cluttering (except neurogenic stuttering caused by acquired brain damage)
- Myofunctional disorders, e.g., tongue thrust
Speech-language pathology is considered medically appropriate treatment for individuals with mental retardation when comorbid disorders such as aphasia or dysarthria are exhibited.
Speech therapy interventions to instruct the beneficiary in English phrases, who has a primary language other than English, are not covered. However, when the primary language of the beneficiary is other than English, speech therapy interventions in the patient's primary language will be covered within the parameters of this LCD.
Other Comments:
There may be rare cases of children who fall under criteria specified in this LCD. Claims for services rendered to children may be covered and approved upon individual consideration.
