This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Speech-Language Pathology.
National Coverage Provisions
Speech-language pathology services are those services provided within the scope of practice of speech-language pathologists and necessary for the diagnosis and treatment of speech and language disorders, which result in communication disabilities and for the diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presence of a communication disability. (See CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Part 3, Section 170.3) (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230.3(A))
A qualified speech-language pathologist for program coverage purposes meets one of the following requirements:
- The education and experience requirements for a Certificate of Clinical Competence in (speech-language pathology) granted by the American Speech-Language Hearing Association; or
- Meets the educational requirements for certification and is in the process of accumulating the supervised experience required for certification
(CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230.3(B))An SLP normally has a master's degree and a Certificate of Clinical Competence (CCC-SLP) or all the requirements leading to a Certificate of Clinical Competence, that is, he or she is in their clinical fellowship year (CFY-SLP).
Speech-language pathology services may be considered reasonable and necessary when the following criteria are met:
- The services shall be considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition;
- The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified therapist;
- If the contractor determines the services furnished were of a type that could have been safely and effectively performed only by or under the supervision of such a qualified professional, the contractor shall presume that such services were properly supervised when required. However, this presumption is rebuttable, and, if in the course of processing a claim, the contractor finds that services were not being furnished under proper supervision, it shall deny the claim and bring this matter to the attention of the Division of Survey and Certification of the Regional Office;
- While a beneficiary's particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary's diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a qualified therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel. Medicare coverage does not turn on the presence or absence of a beneficiary’s potential improvement from the therapy, but rather on the beneficiary’s need for skilled care; and
- The amount, frequency, and duration of the services must be reasonable under accepted standards of practice. The contractor shall consult local professionals or the state or national therapy associations in the development of any utilization guidelines and any one or more of the following:
- In the case of rehabilitative therapy, the patient’s condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time; or
- The services must be necessary for the establishment of a safe and effective maintenance program required in connection with a specific disease state including evaluation, plan of treatment, and staff and family training, when the skills of an SLP are required; or
- In the case of a progressive degenerative disease, service may be intermittently necessary to determine the need for assistive equipment and/or establish a program to maximize function; or
- In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.
Evaluation of Language Disorders:
Re-evaluations are usually focused on the current treatment and might not be as extensive as initial evaluations. Continuous assessment of the patient's progress is a component of ongoing therapy services and is not payable as a re-evaluation. A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services. A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation. Indications for a re-evaluation include new clinical findings, a significant change in the patient's condition, or failure to respond to the therapeutic interventions outlined in the plan of care.
A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.
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. Reevaluation requires the same professional skills as evaluation. The minutes for re-evaluation are documented in the same manner as the minutes for evaluation. Current Procedural Terminology does not define a re-evaluation code for speech-language pathology; use the evaluation code. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.3.C)
The terms, aural rehabilitation, auditory rehabilitation, auditory processing, lipreading and speech reading are among the terms used to describe covered services related to perception and comprehension of sound through the auditory system. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230.3.D.3)
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient's condition for which the service was performed.
Under the Medicare Program, an independently practicing speech pathologist may now bill the Medicare program directly. Section 143 of the Medicare Improvements for Patients and Provider’s Act of 2008 (MIPPA) authorizes the Centers for Medicare & Medicaid Services (CMS) to enroll speech-language pathologists (SLP) as suppliers of Medicare services and for SLPs to begin billing Medicare for outpatient speech-language pathology services furnished in private practice beginning July 1, 2009. Enrollment will allow SLPs in private practice to bill Medicare and receive direct payment for their services. Previously, the Medicare program could only pay SLP services if an institution, physician or nonphysician practitioner billed them.
However, the services of speech-language pathologists may continue to be billed by providers such as rehabilitation agencies, HHAs, CORFs, hospices, outpatient departments of hospitals, and suppliers such as physicians, non-physician practitioners (NPPs), physical and occupational therapists in private practice. When these services are billed by physicians or NPPs, they are covered when billed under the "incident to" provision. "Incident to" services or supplies are defined as those furnished as an integral, although incidental, part of the physician's or NPPs personal professional services in the course of diagnosis or treatment of an injury or illness. These services must be related directly and specifically to a written treatment regimen established by the physician/NPP, after any needed consultation with a qualified speech pathologist, or by the speech pathologist providing such services.
The Medicare Physician Fee Schedule is the method of payment for outpatient physical therapy (which includes outpatient speech-language pathology). Providers must use modifier -GN to identify service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology Plan of Care. (CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.1)
For treatment of auditory processing disorders or auditory rehabilitation/auditory training (including speech-reading or lip-reading), 92507, and 92508 are used to report a single encounter with "1" as the unit of service, regardless of the duration of the service on a given day. These codes always represent SLP services. (CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.3.C)
CPT codes 92626 and 92627 have been added at the end of the comment period at the request of several commenters and are not restricted by the list of ICD-10-CM codes that support medical necessity.
ICD-10-CM code Z01.818 should be reported for pre-laryngectomy examinations.
Standardized cognitive performance testing (CPT code 96125) may be billed to assess cognitive status.
The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Not only should documentation describe the condition of the patient that necessitates the skilled intervention of the speech-language pathologist, but should also report clinical judgment and describe the skilled nature of the treatment. Documenting the skilled components of activities will assist in supporting that the services are medically necessary.
Documentation of speech language services, like other therapy services, must be objective, clear and concise. Documentation in the clinical record must be descriptive, clearly related to functionality, and complement and correlate with other disciplines. Medical necessity may not be established if there is conflicting documentation between disciplines or widely fluctuating abilities indicating an unstable condition. Prior level of functioning must be documented and considered in the patient's treatment plan, to establish reasonable goals for the patient's present condition. Statements such as "mildly impaired to moderately impaired" or "fair plus to good minus" do not offer sufficient objective and measurable information to assess response to therapy and may result in denial of services as not medically necessary. Documentation of discharge planning should be indicated early in the treatment plan.
When the goals of therapy are rehabilitative and a valid expectation of improvement existed at the time services were initiated, or thereafter, the services may be covered even though the expectation may not be realized. Progress reports must document a continued reasonable expectation that the patient's condition will improve significantly, i.e., a measurable and substantial increase in the patient's level of communication, independence, and functional competence compared to the level when treatment was initiated. Documentation should include whatever is deemed pertinent to justify the need for continued intervention, such as any improvements, setbacks, and intervening medical complications.
When the goals of therapy are to 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 (maintenance), and a valid expectation existed at the time services were initiated that skilled therapy intervention would achieve such goals, the services may be covered even though the expectation may not be realized. The record should also make clear why the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel. Progress reports must document a continued reasonable expectation that the maintenance therapy goals are reasonable and achievable and that the skills of a therapist are required to meet those goals. Documentation should include whatever is deemed pertinent to justify the need for continued intervention, such as any improvements, setbacks, and intervening medical complications.
For additional information on Medicare documentation requirements for speech-language pathology services see: CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section, 220, including the subsections under Section 220.