Home Health Speech-Language Pathology

Title XVIII of the Social Security Act, §1814(a)(2)(C) requirements of requests and certifications

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) states Medicare will not cover any services or procedures associated with routine physical checkups

42 CFR §409.42 Beneficiary qualifications for coverage of services

42 CFR §409.43 Plan of care requirements

42 CFR §424.22 Requirements for Home Health services

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 1, §10.2 Home Health Services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §30.1.1 Patient Confined to the Home, §30.1.2 Patient's Place of Residence, §30.2.1 Definition of Allowed Practitioner, §30.2.2 Content of the Plan of Care, §30.3 Under the Care of a Physician or Allowed Practitioner, §30.4 Needs Skilled Nursing Care on an Intermittent Basis (Other than Solely Venipuncture for the Purposes of Obtaining a Blood Sample), Physical Therapy, Speech-Language Pathology Services, or Has Continued Need for Occupational Therapy, §40.1.2.1 Observation and Assessment of the Patient's Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient's Status, §40.1.2.3 Teaching and Training Activities, §40.2 Skilled Therapy Services, §40.2.1 General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy, §40.2.3 Application of the General Principles to Speech-Language Pathology Services, and §50.1 Skilled Nursing, Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) 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 (NCD) Manual, Chapter 1, Part 3, §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 6, §6.2 Medical Review of Home Health Services, §6.2.1 Physician Certification of Patient Eligibility for the Medicare Home Health Benefit, §6.2.1.1 Certification Requirements, §6.2.2 Physician Recertification, §6.2.2.1 Recertification Elements, §6.2.3 The Use of the Patient's Medical Record Documentation to Support the Home Health Certification, §6.2.5 Medical Necessity of Services Provided, §6.2.6 Examples of Sufficient Documentation Incorporated Into a Physician's Medical Record, and §6.2.7 Medical Review of Home Health Demand Bills

Speech-language pathology services are part of a constellation of skilled rehabilitative services designed to improve or restore cognitive functioning, communication skills and/or feeding skills following congenital or acquired disease or injury. Speech-language pathologists (SLPs) use the clinical history, cognitive/language examination and a variety of evaluations to characterize individuals with impairments, functional limitations and disabilities. 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. Such services may also be reasonable and necessary when applied to maintain a level of functioning or prevent or slow further deterioration. Coverage of therapy services, including speech-language pathology services, is based on an individual's need for skilled care as described in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.3. The specific interventions most commonly utilized are tasks/exercises to improve, maintain, train or retrain cognitive/memory skills, feeding skills and overall communication skills; either verbal or non-verbal so the individual can communicate and function as effectively as possible with daily activities.

Restorative/Rehabilitative therapy

In evaluating a claim for skilled therapy that is restorative/rehabilitative (i.e., whose goal and/or purpose is to reverse, in whole or in part, a previous loss of function), it would be entirely appropriate to consider the beneficiary’s potential for improvement from the services. Skilled therapy must be reasonably expected to improve the patient’s functional capacity or adaptation to impairments in order to be covered. 

Maintenance Therapy

Even if no improvement is expected, under the skilled nursing facility (SNF), home health (HH), and outpatient (OPT) coverage standards, skilled therapy services are covered when an individualized assessment of the patient’s condition demonstrates that skilled care is necessary for the performance of a safe and effective maintenance program to maintain the patient’s current condition or prevent or slow further deterioration. Skilled maintenance therapy may be covered when the particular patient’s special medical complications or the complexity of the therapy procedures require skilled care.

Maintenance Program

Coverage of therapy services, including speech-language pathology services, for a maintenance program is based on the individual's need for skilled care in that maintenance program as described in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.1.

Re-evaluation

A re-evaluation would be considered reasonable and necessary for indications described by the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §40.2.3.

1. Speech/hearing treatment

The treatment/intervention, (e.g., prevention, restoration, amelioration, and compensation) and follow-up services for disorders of speech, articulation, fluency and voice, language skills and the cognitive aspects of communication:

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

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

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 aural rehabilitation and related counseling services to individuals with hearing loss and to their family members/caregivers

f. Providing interventions for individuals with central auditory processing disorders

2. Evaluation of speech fluency

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, 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 plan of care. 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. 

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

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

3. Evaluation of sound production

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 for example, with 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, 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 plan of care. 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.

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

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

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

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, 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 plan of care. 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. 

The 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)

5. Behavioral and qualitative analysis of voice and resonance

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, 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 plan of care. 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. 

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

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

6. Speech/Aural rehabilitation following cochlear ear implant

Aural rehabilitation following cochlear implant includes evaluation or aural rehabilitation status and 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. Improve patients' auditory skills pertaining to the suprasegmental aspects

d. Improve patients' ability to discriminate and exhibit improvements in patient’s speech (manner, place and voicing)

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

7. Clinical evaluation of swallowing function

The evaluation of oropharyngeal swallowing dysfunction including the phases of oral preparatory, oral/voluntary and pharyngeal in reference to oral and motility 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 anatomy/physiology (labial control, lingual control, palatal function)

d. Pharyngeal function

e. Laryngeal function

f. Ability to follow directions (alertness)

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

h. Identifying symptoms during attempts to swallow

The clinical examination can be divided into 2 phases:

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

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

*Note: Based on the findings of a 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 examination, in the SLPs judgment, the instrumental examination 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 record.

8. Oral function therapy

This involves the treatment for impairments/functional limitations of mastication, the preparatory, oral, and pharyngeal phases of swallowing. The SLP may make appropriate recommendations (re: diet and compensatory techniques and instruct in direct/indirect therapies) to facilitate oral motor control for feeding.

9. Evaluation of patient for prescription of speech-generating devices (SGDs)

This includes evaluation of language comprehension and production across modalities: written, spoken and gestural. May also include evaluation of motor skills and nonverbal communication strategies (i.e., words, pictures, and vocalization). Includes evaluation of the ability to operate and effectively use an SGD or aid.

10. Patient adaptation and training for use of SGDs

Includes development of operational competence in using an 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 skills in all aspects of device use.

11. Re-evaluation of patient using SGDs

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

12. 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 (modification of voice prosthetic would involve programming or reprogramming device to meet the patient’s needs). Patient is seen postoperatively for training of the voice prosthetic.

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. 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.

15. Developmental testing

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

Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, for example- acquired knowledge, attention, memory, visual spatial abilities, language functions, planning) with interpretation and report.

17. Standardized cognitive performance testing

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

18. Therapeutic exercises

Describes exercises used to strengthen muscles (e.g., jaw, tongue, facial).

19. Therapeutic Activities

Use of dynamic activities to improve functional performance.

20. Cognitive skills development

Develop or restore 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.

21. Sensory Integrative Techniques

This modality may be used for patient’s 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.

22. Self-care/home management training

Compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment.

N/A

N/A

Documentation Requirements

Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to the A/B MAC upon request.

Such documentation should include but is not limited to:

1. The plan of treatment written by the patient’s physician after any needed consultation with the qualified SLP and signed by the physician.

• • • Treatment goals should clearly demonstrate a patient’s need for skilled care.
    • Treatment’s purpose changes (for example) from restoration to maintenance, as well as establishing the efficacy of care that service to prevent or slow decline.
    • If the goals set for the patient are no longer reasonable, then the treatment goal itself should be promptly and appropriately modified and documented to reflect this. 
  • The medical record should also document important communication among all members of the care team regarding the development, course, and outcomes of the skilled observation, assessment, treatment and training performed.

2. When documenting family member/caregiver or communication partner training and education, the documentation should include the person being trained and the effectiveness of the training and education. The training and education should be an adjunct to active therapy with the patient.

3. Outcome and Assessment Information Set (OASIS) data should support the medical necessity of the services documented in the medical records. For therapy services the OASIS MO2200 should be filled out completely and filed with the State Repository. An updated and completed OASIS for the billing period should be on file with the State Repository and in the patient’s medical records to be made available to the A/B MAC upon request.

Evaluation/Re-evaluations

The physician and/or the SLPs evaluation/re-evaluation assess the area for which speech-language therapy is being planned. It must be completed prior to beginning therapy. Evaluations must contain the following information:

1. Reason for referral.

2. Diagnosis and description of the specific problem(s) to be evaluated and/or treated. It should also document the necessity for a course of therapy through objective findings and subjective patient self-reporting.

3. Documentation supporting illness severity or complexity including identifying other health services concurrently being provided for this condition.

4. Identification of durable medical equipment (DME) needed for this condition.

5. Identification of the number of medications the patient is taking and type if known.

6. If complicating factors (complexities) affect treatment, describe why and how.

7. Generalized or multiple conditions and how they may impact the rate of recovery.

8. Mental or cognitive disorder, if applicable.

9. Documentation of medical care prior to the current episode, identification of whether patient was treated for this same condition previously by the same therapy discipline or record of a previous episode of therapy treatment from the same or different therapy discipline in the past year.

10. Documentation is required to indicate objective, measurable beneficiary physical function.

11. Clinician’s clinical judgment or subjective impressions that describe the current functional status of the condition being evaluated.

12. Re-assessments must be performed at least every 30 days by a qualified SLP. The 30-day clock begins with the first therapy’s visit/assessment/measurement/documentation (of the SLP).

13. For multi-discipline therapy cases, a qualified therapist from each of the disciplines must functionally reassess the patient. The therapist must document the measurement results which correspond to the therapist’s discipline and care plan goals in the clinical record.

Plan of Treatment

Services are to be furnished according to a written plan of treatment determined by the physician after any needed consultations with the qualified SLP and signed by the physician after an appropriate assessment (evaluation) of the condition (illness or injury) is completed. In the absence of a verbal order, the written plan of treatment must be completed before active therapy begins. The plan of treatment must be signed by the referring or attending physician prior to billing the service to Medicare. The written plan of treatment established by a physician may not be altered by a SLP.

*Electronic signatures are acceptable if the proper documentation is submitted to the A/B MAC. However, stamped dates are not allowed.

The written plan of treatment must contain the following elements:

a. Diagnosis being treated and the specific problems identified that are to be addressed

b. Specific treatments/interventions being used for each specific problem to attain the stated goals

c. Specific functional goals for the treatments/interventions in measurable terms

d. Amount, frequency, and duration of each treatment/intervention

e. Rehabilitation potential - therapists/physician’s expectation of the patient’s ability to meet the goals at initiation of treatment

Treatment Notes/Progress Notes/Clinical Notes

The HH treatment/progress/clinical notes must document as appropriate:

• The history and physical exam pertinent to the day’s visit (including the response or changes in behavior to previously administered skilled services) 
• The skilled services applied on the current visit
• The patient/caregiver’s immediate response to the skilled services provided, if a family member/caregiver is involved in the patient's care the documentation must also include this
• The plan for the next visit based on the rationale of prior results
• This documentation must be in the clinical notes for each HH visit.

Clinical notes should be written such that they adequately describe the reaction of a patient to his/her skilled care. Clinical notes should also provide a clear picture of the treatment, as well as “next steps” to be taken. Vague or subjective descriptions of the patient’s care should not be used. For example, terminology such as the following would not adequately describe the need for skilled care:

• Patient tolerated treatment well 
• Caregiver instructed in medication management
• Continue with plan of care (POC)

Objective measurements of physical outcomes of treatment should be provided and/or a clear description of the changed behaviors due to education programs should be recorded in order that all concerned can follow the results of the applied services.

When the skilled service is being provided to either maintain the patient’s condition or prevent or slow further deterioration, the clinical notes must also describe:

• 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
• Any other pertinent characteristics of the beneficiary or home

Certification/Recertification

1. The certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient. The encounter must occur no more than 90 days prior to the HH start of care date or within 30 days after the start of care.

2. Content of the Physician’s Certification—No payment may be made for the HH speech-language pathology services unless the physician certifies that: 

1. A plan of care for furnishing such services is or was established by the physician after any needed consultation with the qualified SLP and reviewed by the physician every certification/re-certification period
2. The services are or were furnished while the patient was under a written plan of care by a physician
3. The services are or were required by the patient. The services must be medically necessary for the skilled need provided
4. The patient must be homebound

3. Certifications and re-certifications by the physician, must be on file and available to the A/B MAC upon request.

4. Certifications are required upon initiation of therapy and with every certification/re-certification period thereafter for HH speech-language pathology services. If the requirements for certification are not met then claims for subsequent episodes of care, which require a recertification, will not be covered- even if the requirements for recertification’s are met. Re-certifications are needed at least every 60 days when there is a need for continuing home care.

5. The referring/attending physician establishes or reviews the plan of treatment and makes the necessary certifications. The referring/attending physician must sign and date all certifications/re-certifications. Signature means an actual handwritten signature or electronic signature.

6. Documentation should indicate the prognosis for potential restoration of function in a reasonable and generally predictable period of time, or the need to establish a safe and effective maintenance program.

Maintenance Therapy

The skills of a qualified therapist (not an assistant) are needed to perform maintenance therapy:

1. Coverage of therapy services to perform a maintenance program is not determined solely on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care. Individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. 

2. An individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program” and ongoing that the patient continues to require such services to prevent deterioration and ongoing that the patient continues to require such services to prevent deterioration. 

3. Maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program. 

4. In situation 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.

Discharge Planning

1. Should be addressed at the initiation of therapy.

2. Documentation must support that the SLP discussed discharge planning with the patient/caregiver prior to the final visit.

Ben-Yishay Y, Diller L. Cognitive remediation in traumatic brain injury: Update and issues. Arch Phys Med Rehabil. 1993;74(2):204-213.

Lawton MP, Brody EM. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179-186.

Nicolosi L, Harryman E, and Kersheck J. Terminology of Communication Disorders. 5th ed. Baltimore, MD: Lippincott, Williams & Wilkes; 2004.

• Home Health
• Speech Language Pathology
• SLP