Speech - Language Pathology (SLP) Services: Communication Disorders

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for speech/language services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for speech/language services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site.

IOM Citations:

• CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
  • Chapter 8 Coverage of Extended Care (SNF) Services Under Hospital Insurance
  • Chapter 12 Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage
  • Chapter 15, Covered Medical and Other Health Services, Section 220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance and Section 230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
• CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Part 3, Section 170.2 Melodic Intonation Therapy
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and CORF/OPT Services
• CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Local Coverage Determinations, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

• Title XVIII of the Social Security Act, Section 1835(2)(D) outlines requirements for outpatient speech pathology services including certification and recertification of the plan of care.
• Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
• Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Code of Federal Regulations (CFR) References:

• CFR, Title 42, Section 409.32 Criteria for skilled services and the need for skilled services
• CFR, Title 42, Section 410.61 Plan of treatment requirements for outpatient rehabilitation services
• CFR, Title 42, Section 424.24(c) Requirements for medical and other health services furnished by providers under Medicare Part B
• CFR, Title 42, Section 485.705 Personnel Qualifications
• CFR, Title 42, Section 485.715 Condition of participation: Speech pathology services

Other References:

• Jimmo Settlement information located at www.CMS.gov/Center/Special-Topic/Jimmo-Center.html

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

This LCD provides guidelines for selected speech-language pathology (SLP) services for communication disorders.

The speech-language pathology services discussed in this LCD are those evaluation and therapeutic services necessary for the diagnosis and treatment of speech and language disorders, which result in communication disabilities; and for the diagnosis and treatment of cognitive communication impairments.

Speech-language pathology services are designed to improve or restore speech and language functioning (communication) following disease, injury or loss of a body part. Clinicians use the clinical history, systems review, physical 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 interventions tailored to the specific needs of the individual patient.

Covered Indications

For information regarding skilled therapy services, please see CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 8 and Chapter 15, Sections 220 and 230.

For information on conditions necessary for SLP services to be considered reasonable and necessary, please refer to the applicable CMS IOM references.

*Restorative/Rehabilitative Therapy

Please see IOM Publication 100-02, Medicare Benefit Policy Manual, Chapters 8 and Chapter 15 Section 220.3.D, for information on rehabilitative therapy and necessary documentation. Documentation must justify the necessity of the services.

**Maintenance Therapy/Program (skilled)

Please see CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Chapter 12 and Chapter 15, Section 220.3.D, for information on maintenance therapy and skilled therapy services and necessary documentation for those services. Documentation must justify the necessity of the services.

SLP EVALUATION AND DIAGNOSTIC SERVICES

The evaluation of a patient's level of function is focused on identifying what the patient wants and needs to do, and on identifying those factors that help or hinder the performance of those activities. Please see CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 for information regarding clinician evaluation, re-evaluation and documentation of SLP evaluation and diagnostic services.

Speech/hearing evaluation

In addition to the general information in the above CMS manual, the evaluation includes the identification, assessment, diagnosis, and evaluation for disorders of speech, articulation, fluency, and voice (including respiration, phonation, and resonance); language skills (involving the parameters of phonology, morphology, syntax, semantics, and pragmatics, and including disorders of receptive and expressive communication in oral, written, graphic, and manual modalities); and cognitive aspects of communication (including communication disability and other functional disabilities associated with cognitive impairment).

Speech/hearing evaluation for disorders of the auditory system may also be considered here, such as auditory processing evaluation. For more information please see CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220, referenced in the CMS National Coverage Policy section of this policy.

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

This includes selection of a standard or indwelling voice prosthesis, determination of appropriate size prosthesis and fitting a tracheostomy valve and includes instructions for care and cleaning.

Evaluation of patient for prescription of speech-generating devices

Evaluation of language comprehension and production across modalities: written, spoken, and gestural and may also include evaluation of the ability to operate and effectively use a speech generating device or aid. This evaluation may also include evaluating motor skills and nonverbal communication strategies (e.g. words, pictures, and vocalizations).

Assessment of Aphasia

The assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, and writing, with interpretation and report (per hour). Examples of assessments used include the Boston Diagnostic Aphasia Examination, the Western Aphasia Battery, and the Minnesota Differential Diagnosis Examination of Aphasia.

A comprehensive aphasia assessment is generally covered once.

Please see CMS IOM 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230.3 for documentation requirements of therapy services.

Developmental test administration; extended

This includes assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed; with interpretation and report.

Standardized cognitive performance testing

This includes testing such as the Ross Information Processing Assessment (per hour) including both face-to-face time and non-face-to-face time interpreting these test results and preparing the report. Standardized tests may be norm-referenced (results are interpreted based on established norms and compare test-takers to each other) or criterion-referenced (results are interpreted based on the person’s performance/ability to complete tasks or demonstrate knowledge of a specific topic).

SLP THERAPEUTIC SERVICES

Speech/hearing therapy

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 aspect of communication.

1. Providing consultation, counseling, and making referrals when appropriate.
2. Providing training and support to family members/caregivers and other communication partners of individuals with speech, voice, language, communication, fluency and hearing disabilities.
3. 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.
4. Establishing effective use of appropriate prosthetic/adaptive devices for speaking.
5. Providing rehabilitation services for the auditory system, and related counseling services to individuals with hearing loss and to their family members/caregivers. For further details, please see CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220, referenced in the CMS National Coverage Policy section of this policy.
6. Providing interventions for individuals with central auditory processing disorders; and/or
7. Modification or training in use of a voice prosthetic. Modifications in a voice prosthetic to supplement oral speech would be appropriate and should be carried out by a speech-language pathologist. The patient is seen for sizing, fitting, placement or replacement and training of the voice prosthetic.

Speech/hearing therapy (group)

For the purpose of performing group therapy, a group is defined as two or more individuals receiving active therapy, Please see CMS IOM 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230 for more information on group SLP services.

Therapeutic services (patient adaptation and training) for the use of speech-generating devices

Patient adaptation and training for the use of speech-generating devices includes the development of operational competence in using a speech-generating device 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.

SLP THERAPEUTIC PROCEDURES

Therapeutic procedures are treatments that attempt to reduce impairments and improve or maintain function (or prevent further deterioration) through the application of clinical skills or services. Please see CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 for more information on documentation for therapeutic interventions.

Services provided concurrently by different types of clinicians may be covered if separate and distinct goals are documented in the treatment plans.

Therapeutic exercises

Therapeutic exercise incorporates rehabilitation principles related to strengthening, endurance, flexibility, and range of motion. Therapeutic exercise may be performed with a patient either actively, actively assisted, or passively participating. Therapeutic exercises may be used to strengthen muscles (e.g., jaw, tongue, facial).

Therapeutic activities

Therapeutic activities involve the use of dynamic activities to improve functional performance in a progressive manner; e.g., increase in volume of voice through respiratory activities. They require the skills of a clinician and are designed to address a specific functional need of the patient. Please see CMS IOM Pub 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30.2.2.1 and Section 30.4.1.2 for more information.

Cognitive skills development

This service describes interventions used to improve, maintain, or prevent further deterioration of cognitive skills, (e.g., attention, memory, problem solving) with direct (one-on-one) patient contact by the clinician. It may be medically necessary for patients with acquired cognitive impairments from head trauma, acute neurological events (including cerebrovascular accidents), or other neurological disease.

Sensory integrative techniques

This activity focuses on sensory integrative techniques to enhance sensory processing and to promote adaptive responses to environmental demands, with direct (one-on-one) patient contact by the clinician. Please see CMS IOM 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230 for more information. An example is a patient with several oral problems secondary to a stroke; the sensory integrative techniques used to facilitate speech might include flossing or brushing techniques.

Self-care/home management training

This training includes activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment, direct one-on-one contact by the clinician. Please see CMS IOM 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220 for more information.

Limitations

The following are considered not reasonable and necessary:

1. For information regarding therapy performed repetitively to maintain a level of function, please see CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 8; Section 30; Chapter 12, Section 10; and Chapter 15, Sections 220 and 230.
2. Please see CMS IOM 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230.3.D for information regarding screening assessments.
3. Please see CMS IOM 100-02, Chapter 15, Section 230.3.D for information regarding routine screening for hearing acuity or evaluations.
4. Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument is considered a screening service. Please see CMS IOM Medicare Benefit Policy Manual, Chapter 15, Section 80.2 regarding psychological and neuropsychological tests.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.

N/A

N/A

Refer to the Local Coverage Article: Billing and Coding: Speech Language Pathology (SLP) Services: Communication Disorders, A54111 for all coding information.

Documentation Requirements

1. All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
3. The medical record documentation must support the medical necessity of the services as stated in this policy.
4. Documentation of speech-language pathology services includes any entry into a patient's medical record such as a consultation report, initial examination report, patient informed consent notation, progress note, flow sheet/checklist that identifies the care/service that was provided, reexamination report or summation of care.
5. The medical record must identify the physician or non-physician practitioner responsible for the general medical care of the patient and the dates and outcomes of the clinical visits to this provider for continued evaluation during the course of therapy.
6. Refer to the "Coverage Indications, Limitations, and/or Medical Necessity" section of this policy for additional guidelines pertaining to the documentation requirements for the individual treatments/modalities.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Contractor is not responsible for the continued viability of websites listed.

Other Contractor Policies

Contractor Medical Directors

1. American Speech-Language Hearing Association. (2001). Guidelines for Medicare coverage of speech-language pathology services.
2. DynCorp Therapy PSC Protocol
3. Guide to Physical Therapist Practice