Outpatient Speech Language Pathology

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations

Title XVIII of the Social Security Act, §1835(2)(D) lists requirements for certification and recertification of outpatient speech pathology services

42 CFR §410.61 Plan of treatment requirements for outpatient rehabilitation services

42 CFR §424.24 Requirements for medical and other health services furnished by providers under Medicare Part B

42 CFR §485.705 Personnel qualifications

42 CFR §485.715 Condition of participation: Speech pathology services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §20.4.1 Diagnostic Services Defined

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy and §40.2.3 Application of the General Principles to Speech-Language Pathology Services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 8, §30.4 Direct Skilled Therapy Services to Patients and §30.4.1.2E Application of Guidelines: Maintenance Therapy

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 12, §10 Comprehensive Outpatient Rehabilitation Facility (CORF) Services Provided by Medicare, §20 Required and Optional CORF Services, §20.2 Optional CORF Services and §40.4 Speech Language Pathology Services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.3 Audiology Services, §220.1.1 Care of a Physician/Nonphysician Practitioner (NPP), §220.1.2 Plans of Care for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services, §220.1.3 Certification and Recertification of Need for Treatment and Therapy Plans of Care, §220.1.4 Requirement That Services Be Furnished on an Outpatient Basis, §220.2 Reasonable and Necessary Outpatient Rehabilitation Therapy Services, §220.3 Documentation Requirements for Therapy Services, §230 Practice of Physical Therapy, Occupational Therapy and Speech-Language Pathology, §230.3 Practice of Speech-Language Pathology, §230.5 Physical Therapy, Occupational Therapy and Speech-Language Pathology Services Provided Incident to the Services of Physicians and Non-Physician Practitioners (NPP) and §230.6 Therapy Services Furnished Under Arrangements With Providers and Clinics

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §50.1 Speech Generating Devices, §50.2 Electronic Speech Aids, §50.3 Cochlear Implantation and §50.4 Tracheostomy Speaking Valve

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 3, §170.1 Institutional and Home Care Patient Education Programs, §170.2 Melodic Intonation Therapy and §170.3 Speech-Language Pathology Services for the Treatment of Dysphagia

CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, §3.3.2.4 Signature Requirements

CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, §13.5.1 General Requirements

Speech Language Pathology services are those services necessary for the diagnosis and treatment of speech, language and cognitive communication disorders which result in communication disabilities. Speech Language Pathology also includes evaluation and treatment of swallowing.

Speech Language Pathology services are part of a constellation of skilled services as described by the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.3. Acquired etiologies include but are not limited to stroke, brain tumor, traumatic brain, anoxic or toxic encephalopathy, and nondegenerative and degenerative neurologic diseases (including the dementias). Speech Language Pathologists (SLPs) use the clinical history, cognitive/language examination and a variety of evaluations to characterize individuals with impairments, activity limitations, disabilities and participation restrictions. Impairments, functional limitations and disabilities thus identified are then addressed by the design and implementation of therapeutic intervention tailored to the specific needs of the individual patient. The specific interventions most commonly utilized are tasks/exercises to improve, maintain, train or retrain speech/language, cognitive/memory skills, swallowing skills and overall communication skills; either verbal or non-verbal so the individual can communicate and function as effectively as possible with daily activities. In order to facilitate increased participation in life, interventions may also include individualized communication partner training and education in order to help the individual achieve relevant personal goals appropriate to his or her cultural and/or language community.

For outpatient settings, references to "physicians" throughout this policy include the following non-physician practitioners (NPPs): nurse practitioners (NPs), clinical nurse specialists (CNSs) and physician assistants (PAs). Such NPPs may certify, order and establish the plan of care for Speech Language Pathology and dysphagia services by SLPs as authorized by State law.

The SLP assesses a patient and develops a plan for treatment as described by CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §230.3.

Restorative/Rehabilitative therapy

Restorative / Rehabilitative therapy is intended for patients for whom the goal of therapy is to reverse some loss of function as described in CMS Internet-Only Manual Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220.2.

Maintenance therapy

Maintenance therapy is intended for patients for whom the goal of treatment is to slow or prevent deterioration in function as described in CMS Internet-Only Manual Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220.2.

Evaluation/Re-evaluation

Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient's performance and functional abilities. Evaluation is warranted, e.g., for a new diagnosis or when a condition is treated in a new provider setting. These evaluative judgments are essential to development of the plan of care (POC), including goals and the selection of interventions. The time spent in the evaluation does not also count as treatment time.

Re-evaluation is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, decline, or change in the patient's condition or functional status that was not anticipated in the POC. Some regulations and State Practice Acts require re-evaluation at specific intervals. A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment or terminating services. Re-evaluation requires the same professional skills as an evaluation. 

1. Laryngoscopy, flexible or rigid telescopic, with stroboscopy

Flexible nasoendoscopy or rigid oral endoscopy is performed using a strobe light correlated to voice fold vibration, which permits vocal tract structures to be visualized in an apparent slow-motion format in order to assess the effect of pathology on the process of voicing and to determine appropriate therapy strategies.

2. Modification or training in use of voice prosthetic

Modifications in voice prosthetic to supplement oral speech would be appropriate and should be carried out by a SLP. The patient is seen for sizing, fitting, placement or replacement and training of the voice prosthetic.

3. Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual

Speech/hearing therapy is the treatment/intervention, (e.g., prevention, restoration, amelioration, and compensation) and follow-up service for disorders of speech, articulation, fluency, voice, and language skills as well as for impairments of cognition, language and pragmatics found in cognitive communication disorders.

These services may include:

a. Providing consultation, counseling, and making referrals when appropriate;

b. Providing education, training and support to family members/caregivers and other communication partners of individuals with speech, voice, language, fluency, hearing, cognitive communication disorders and swallowing disorders;

c. Developing and establishing effective augmentative and alternative communication techniques and strategies, including selecting, prescribing and dispensing of aids and devices as identified by State Practice Acts and training individuals, their family members/caregivers, and other communication partners in their use;

d. Selecting, fitting, and establishing effective use of appropriate prosthetic/adaptive devices for speaking;

e. Providing audiologic rehabilitation, that is a facilitative process that provides intervention to address the impairments, activity limitations, participation restrictions and possible environmental and personal factors that may affect the communication, functional health, and well-being of persons with hearing impairment or by others who participate with them in those activities, including related counseling services to individuals with hearing loss and to their family members/caregivers, and /or;

f. Providing interventions for individuals with central auditory processing disorders.

Treatment may include individualized communication/ partner education and training appropriate to the individual’s cultural and language community.

Modifications in voice prosthetic to supplement oral speech would be appropriate and should be carried out by a SLP. The patient is seen for sizing, fitting, placement or replacement and training of the voice prosthetic.

4. Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals 

A group for the purpose of performing group therapy will be defined as:

a. Two or more patients per therapy receiving active therapy but not 1-on-1 treatment, and;

b. The patients may be performing the same therapy or a different therapy but the SLP is instructing all the patients in the group.

5. Nasopharyngoscopy with endoscope (separate procedure) 

Nasopharyngoscopy with endoscope is the visualization of the nasopharynx and vocal tract during speech production with an endoscope to assess and treat patients with resonance and/or aeromechanical disorders.
 
6. Nasal Function Studies

Nasometry assessment is an instrumental assessment of resonance. This assessment provides numbers that represent a ratio between oral resonance and nasal resonance during production of specific syllables, phrases, and reading passages. Normative data is available so that a patient's scores can be interpreted relative to normal. Nasometry helps quantify hypernasality and hyponasality. It also provides a baseline for measuring change following management-therapeutic or surgical.
 
7. Laryngeal function studies

Laryngeal function studies are the acoustic and aerodynamic measures used to evaluate vocal function.

8. Evaluation of speech fluency

This evaluation is the identification, assessment, and diagnosis of the following disorders:

- Fluency (e.g., stuttering, cluttering)

9. Evaluation of speech sound production

This evaluation is the identification, assessment, and diagnosis of the following disorders:

- Speech sound production (e.g., articulation, phonological process, apraxia, dysarthria)

10. Evaluation of speech sound production with evaluation of language comprehension and expression

This evaluation is the identification, assessment, and diagnosis of the following disorders:

- Speech/sound production (e.g., articulation, phonological process, apraxia, dysarthria)
- Language skills (e.g., morphology, syntax, semantics, and pragmatics; also including disorders of receptive and expressive communication in oral, written, graphic, and manual modalities)

11. Behavioral and qualitative analysis of voice and resonance

This evaluation is the identification, assessment, and diagnosis of the following disorders:

- Voice and resonance disorders (e.g., dysphonia, aphonia, laryngospasm, dystonia, hypernasality, hyponasality)

12. Treatment of swallowing dysfunction and/or oral function for feeding

Treatment of swallowing dysfunction involves the treatment for impairments and/or functional limitations of mastication (i.e., chewing), and/or swallowing (including preparatory, oral, and pharyngeal phases). Swallowing or oral function therapy may also involve indirect treatment to include recommendations regarding therapeutic diet, compensatory strategies/techniques and instructions to facilitate swallowing.

13. Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech

The patient is evaluated for a voice prosthetic. The patient's ability to perform the mechanics necessary to provide voice, care and cleaning of the unit are evaluated, as well as the patient's preference for the unit (examples of voice prosthetics are tracheoesophageal valves, electrolarynges, speaking valves, and voice amplifiers).

Some of these devices are directly attached to the patient and some are not. They amplify a weak or inaudible voice and supply voice for a non-verbal patient. The voice prosthetic allows the patient to use his own vocal production to communicate to the other people.

14. Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour; Each additional 30 minutes

Evaluation of patients who are non-verbal or who do not have the capacity for verbal communication, that may need augmented communication devices for communication purposes. Augmented communication devices may include the use of a computer device, book communication, pad/writing tools, etc.

15. Therapeutic service(s) for the use of non-speech generating device (SGD), including programming and modification

Services to provide treatment of patients who are non-verbal or who do not have the capacity for verbal communication, that may need augmented communication devices for communication purposes. Augmented communication devices may include the use of a computer device, book communication, pad/writing tools, etc.

16. Evaluation for prescription for speech-generating augmentative and alternating communication device, face-to-face with the patient; first hour; Each additional 30 minutes

Evaluation of a patient for prescription of SGDs includes evaluation of language comprehension and production across modalities: written, spoken, and gestural. This may also include evaluation of motor skills and nonverbal communication strategies (e.g., words, pictures, and vocalizations). Evaluation includes the ability to operate and effectively use a SGD or aid. Prior to the delivery of the SGD, the patient has had a formal evaluation of their cognitive and communication abilities by a SLP.

17. Re-evaluation of a patient using SGDs

Re-evaluation of the patient using SGDs or aids to supplement oral speech, assess the need for continued use or identify the need for changes in objectives.

18. Therapeutic services for the use of SGD, including programming and modification

Patient adaptation and training for use of SGDs includes the development of operational competence in using a SGD or aids to include customizing the features of the device to meet the specific communication needs of each patient and providing opportunities for developing skill in all aspects of device use.

19. Evaluation of oral and pharyngeal swallowing function

Clinical evaluation of swallowing function is the evaluation of oropharyngeal swallowing dysfunction including the phases of oral preparatory, oral/voluntary and pharyngeal in reference to problems in the oral cavity and pharynx.

The bedside clinical examination may include:

a. History of patient's disorder and awareness of swallowing disorder, and indications of localization and nature of disorder

b. Medical status including nutritional and respiratory status

c. Oral structures (lips, tongue, jaw, hard, and soft palate, oral pharynx, teeth, mucosa)

d. Pharyngeal function; swallow initiation; impression of signs of aspiration such as coughing or wet-gurgly voice

e. Laryngeal function; laryngeal elevation during swallow; coordination of respiration and swallowing; airway protection

f. Oral bolus manipulation and transport through pharyngeal and upper esophagus

g. Ability to follow directions (alertness)

h. Interventions used to facilitate safe swallow (compensatory strategies such as chin tuck, dietary changes, etc.)

The clinical examination can be divided into 2 phases:

a. The pre-swallowing assessment/preparatory examination with no swallow, and;

b. The initial swallow examination with actual swallow while physiology is observed.

Note: Based on the findings of the clinical evaluation, an instrumental examination may or may not be recommended. Despite positive clinical findings there are times when an instrumental examination may not be indicated (e.g., the patient is too medically unstable to tolerate a procedure, the patient is unable to cooperate or participate in an instrumental exam; in the SLPs judgment, the instrumental exam would not change the clinical management of the patient). In addition, because of the documented limitations of the clinical evaluation of swallowing, there may be scenarios where despite a negative clinical examination an instrumental examination may still be indicated. In these cases, information supporting the medical necessity of the instrumental examination should be documented in the medical records.

20. Motion fluoroscopic evaluation of swallowing function by cine or video recording

Evaluation of swallowing involving swallowing of radio-opaque materials is the evaluation of oropharyngeal and upper digestive swallowing dysfunction including bolus coordination and transport during deglutition, airway protection, the benefit of compensatory strategies and effective swallowing. The SLP must be assured that the patient is alert and has the ability to follow directions.

Guidance for the appropriate supervision of this study is given in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §230.3.

Note: Diagnostic radiographic studies are recommended when results of the bedside or clinical evaluation are inconclusive or suggest dysphagia and/or aspiration.

21. Flexible endoscopic evaluation of swallowing by cine or video recording

An endoscopic evaluation of swallowing (FEES) involves placement of a flexible endoscope transnasally to the hypopharynx. The procedure permits direct visualization of anatomy as well as an assessment of amplitude, speed/briskness, and symmetry of movement of the velopharyngeal sphincter, base of tongue, pharynx, and larynx. Sensation is assessed by noting the reaction of the patient to the presence of the endoscope. Findings include briskness of swallow initiation, timing of bolus flow and swallow initiation, adequacy of bolus driving/clearing forces, adequacy of velar and laryngeal valving forces, penetration and/or aspiration before or after the swallow, and presence of hypopharyngeal reflux. 

The skills and competencies required of clinicians providing this service are described in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §230.3.

22. Flexible endoscopic evaluation, laryngeal sensory testing by cine or video recording

An endoscopic evaluation of swallowing with sensory testing is the performance of a FEES with the incorporation of sensory testing. The sensory evaluation is completed by delivering pulses of air at sequential pressures to elicit the laryngeal adductor reflex. A sensory threshold is thus established.

Motor evaluation is completed by giving various food items with different consistencies while factors such as oral transit time, inhibition of swallowing, laryngeal elevation, spillage, residue, condition of swallow, laryngeal closure, reflux, aspiration, and ability to clear residue are monitored. The entire procedure may be done at bedside. The use of anesthesia may interfere with the sensory test and is usually not indicated.

Note: Other instrumental assessments may be indicated to study swallowing. The appropriateness of the assessment procedure will be based on the nature of the disorder and standard of practice.

23. Flexible endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording

Flexible endoscopic evaluation of swallowing and laryngeal sensory testing (FEESST) is using a flexible endoscope in the evaluation of swallowing and laryngeal sensory testing by cine or video recording. Special equipment includes a sensory stimulator that allows quantification of stimuli. Sensory evaluation is complete by delivering pulses of air sequentially increased to elicit the laryngeal adductor reflex.

24. Evaluation of auditory rehabilitation status, first hour; Each additional 15 minutes; Auditory rehabilitation; prelingual hearing loss; Auditory rehabilitation; post lingual hearing loss

Auditory rehabilitation consists of treatment that focuses on comprehension, and production of language in oral, signed or written modalities; speech and voice production, auditory training, speech reading, multimodal (e.g., visual, auditory-visual, and tactile) training, communication strategies, education and counseling. In determining the necessity for treatment, the patient's performance in both clinical and natural environment should be considered.

Auditory rehabilitation following cochlear implant includes hearing, and therapeutic services with or without speech processor programming. This may include:

a. Extensive auditory rehabilitation therapy for patients with cochlear implants focusing on audition, cognition, language and speech skills

b. Family member or caregiver training for auditory verbal techniques

c. Improving the patient's auditory skills pertaining to the suprasegmental aspects

d. Improving the patient's ability to discriminate and exhibit improvements in patient's speech (manner, place and voicing)

Note: Speech processor programming is usually performed by an audiologist.

25. Cholinesterase inhibitor challenge test for myasthenia gravis

The role of the SLP is to assess the patient's speech characteristics (e.g., dysarthria, intensity, voice quality, strength, resonance and endurance in isolated word production task, conversation, and speech) during cholinesterase inhibitor challenge testing.

26. Assessment of aphasia

Evaluation, assessment, diagnosis, and identification of a communication disorder characterized by complete or partial impairment of language comprehension, formulation and use; excluding disorders associated with primary sensory, general mental deterioration or psychiatric disorders by standardized or informal measures.

27. Developmental testing

This includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments with interpretation and report.

28. Neurobehavioral status exam

This is a clinical assessment of thinking, reasoning and judgment (e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities) with interpretation and report.

29. Standardized cognitive performance testing

Evaluate abilities of executive (cognitive) function including: assessment of learning abilities, memory and working memory, abstract thought, language, and attention.

30. Group therapy for dysphagia

Group therapy can be beneficial for dysphagia patients. Dysphagia patients are all working on aspiration precautions, diet modification/advancement and similar compensatory swallowing techniques, i.e., cues for small bites/sips, repeat swallows, throat clearing, chin tuck, head turns, slow pace and for carryover of skills practiced individually in therapy. As with other group therapies, dysphagia therapy patients often need to do a variety of strengthening/range of motion (ROM)/coordination exercises (oral motor, pharyngeal strengthening, breathing support exercises) regardless of the degree of impairment. Therefore, whether a patient is nothing by mouth (NPO) or on a feeding tube and being transitioned to an oral diet or on a mechanical soft with nectar thick liquid diet, these patients can in fact be grouped together and achieve functional outcomes.

31. Development of cognitive skills

This is the developing or restoring of cognitive status (alertness, orientation, attention, memory, problem solving, recall, affect, reasoning, judgment, organization, and retention) and informal assessment/observation of cognitive abilities necessary for performing daily activities.

32. Sensory Integrative Techniques

This modality may be used for patients needing oral sensory stimulation. The use of sensory integrative techniques is considered reasonable and necessary when patients must develop adaptive skills for sensory processing. When there has been a disruption of the auditory, vestibular, proprioceptive, tactile and/or visual system, interventions are required to assist the patient in remaining functional in their environment. The loss of sensory systems often compromises the safety of the patient; therefore, therapy should provide adaptations that allow the patient to interact with their environment that promotes well-being.

33. Self-care/home management training

Self-care/home and community reintegration management training includes but is not limited to compensatory training for life participation in communication situations in both home and community environments, meal preparation, safety procedures, and instructions in use of assistive technology methods/devices/adaptive equipment.

N/A

N/A

Documentation Requirements

Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220.3.

1. Documentation supporting medical necessity should be legible and support those services were covered and performed. This documentation must be made available to the A/B MAC upon request.

2. The documentation in the medical records should have sufficient information to determine that a service was performed on specific dates, and the medical necessity of the service(s) rendered.

3. It is expected that the documentation in the patient’s medical record will reflect the need for the skilled services provided. The medical record should document important communication among all members of the care team regarding the development, course, and outcomes of the skilled observations, assessments, treatment, and training performed.

4. If the signed order includes a POC, no further certification of the plan is required. Payment is dependent on the certification of the POC rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.

5. Required documentation:

• Evaluation and POC including any other pertinent characteristics of the beneficiary
• Certifications and recertifications
• The history and physical exam pertinent to the patient’s care, (including the response or changes in behavior to previously administered skilled services)
• The skilled services provided
• A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences
• The complexity of the service to be performed
• Progress reports written by the clinician - Services related to progress reports are to be furnished on or before every 10th treatment day
• Treatment notes for each treatment day (may also serve as progress reports when required information is included in the notes)
• The Discharge Note (or Discharge Summary) is required for each episode of outpatient treatment and must be written by the clinician
• When appropriate, a separate justification statement for services that are more extensive than is typical for the condition treated

NOTE: Documentation must comply with the elements outlined in CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220.3 Documentation Requirements for Therapy Services.

Note: For group therapy for dysphagia the following criteria should be documented in the patient's medical records:

• Rendered under an individualized POC
• Has less than 5 group members
• Does not represent the entire plan of treatment
• Requires the skills of a licensed therapist
• Promotes independent swallowing

Additional Documentation Requirements:

a. Documentation of the specific skilled treatments used in the group and how they relate to the POC
b. Documentation of number of members in group

6. Documentation should justify:

• The individual is under the care of a physician or NPP
• Services require the skills of a therapist
• Services are of the appropriate type, frequency, intensity and duration for the individual needs of the patient

7. For restorative/rehabilitative therapy documentation should establish:

• Variables that influence the patient's condition
• Services provided at the time of treatment
• Objective measurements that the patient is making progress toward goals. If it becomes apparent at some point that the goal set for the patient is no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of skilled services.

Measurements include but are not limited to standardized tests, rating scales, consumer self-ratings of communication participation, and measurable changes in communicative participation as gauged by changes in actual life roles and situations outside the treatment room. 

-Clinical rationale for continued treatment and/or reasons for lack of progress
-Recommended changes to the POC
-Ongoing reassessment of the patient’s response to treatment

Maintenance Programs

Maintenance program 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.

Skilled therapy services that do not meet the criteria for rehabilitative therapy may be covered in certain circumstances as maintenance therapy under a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to prevent or slow further deterioration in function.

Coverage for skilled therapy services related to a reasonable and necessary maintenance program is available in the following circumstances:

• Establishment or design of maintenance programs. If the specialized skill, knowledge and judgment of a qualified therapist are required to establish or design a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration, the establishment or design of a maintenance program by a qualified therapist is covered. If skilled therapy services by a qualified therapist are needed to instruct the patient or appropriate caregiver regarding the maintenance program, such instruction is covered. If skilled therapy services are needed for periodic re-evaluations or reassessments of the maintenance program, such periodic re-evaluations or reassessments are covered.

• Delivery of maintenance programs. Once a maintenance program is established, coverage of therapy services to carry out a maintenance program turns on the beneficiary’s need for skilled care. A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel. In such situations, coverage is not provided. However, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program. Such skilled care is necessary for the performance of a safe and effective maintenance program only when (a) the therapy procedures required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy procedure or (b) the particular patient’s special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy procedures. Unlike coverage for rehabilitation therapy, coverage of therapy services to carry out a maintenance program does not depend on the presence or absence of the patient’s potential for improvement from the therapy.

The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist, or whether they can be safely and effectively carried out by nonskilled personnel or caregivers.

Where services that are required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to perform the procedure safely and effectively, the services would be covered speech language pathology services. Further, where the particular patient’s special medical complications require the skills of a qualified therapist to perform a therapy service safely and effectively that would otherwise be considered unskilled, such services would be covered speech language pathology services. It is expected that the documentation in the patient’s medical record will reflect the need for the skilled services provided. In situations where the maintenance program is performed to maintain the patient’s current condition, such documentation would serve to demonstrate the program’s effectiveness in achieving this goal. When the maintenance program is intended to slow further deterioration of the patient’s condition, the efficacy of the services could be established by documenting that the natural progression of the patient’s medical or functional decline has been interrupted. Assessments of all goals must be performed in a frequent and regular manner so that the resulting documentation provides a sufficient basis for determining the appropriateness of coverage.

The maintenance program provisions do not apply to the speech language pathology services furnished in a CORF because the statute specifies that CORF services are rehabilitative.

CORF Services

CORF social and/or psychological services do not include services for mental health diagnoses. Social and/or psychological services are covered only if the patient's physician or the CORF physician establishes that the services directly relate to the patient's rehabilitation plan of treatment and are needed to achieve the goals in the rehabilitation plan of treatment. Social and/or psychological services are those services that address the patient's response and adjustment to the rehabilitation treatment plan: rate of improvement and progress towards the rehabilitation goals, or other services as they directly relate to the speech-language pathology plan of treatment being provided to the patient.

American Speech-Language-Hearing Association. Evidence-Based Practice in Communication Disorders. Accessed October 13, 2022.

American Speech-Language-Hearing Association. Medicare CPT Coding Rules for Speech-Language Pathology Services. Accessed October 13, 2022.

American-Speech-Language-Hearing Association. Preferred Practice Patterns for the Profession of Audiology. Accessed October 13, 2022.

Hinckley J, Douglas N, Goff R, Nakano E. Evidence, expertise and client values intertwined: Aphasia examples. Seminar presented at: Convention of the American Speech-Language Hearing Association; November 2010; Philadelphia, PA.

International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization (WHO); 2001.

Nicolosi L, Harryman E, Kresheck J. Terminology of Communication Disorders. 3rd ed. Baltimore, MD: Williams & Wilkins; 1978.

• Speech Language Pathology