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.
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.
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.
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
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.
- Providing consultation, counseling, and making referrals when appropriate.
- Providing training and support to family members/caregivers and other communication partners of individuals with speech, voice, language, communication, fluency and hearing disabilities.
- 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.
- Establishing effective use of appropriate prosthetic/adaptive devices for speaking.
- 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.
- Providing interventions for individuals with central auditory processing disorders; and/or
- 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 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 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 188.8.131.52 and Section 184.108.40.206 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.
The following are considered not reasonable and necessary:
- 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.
- Please see CMS IOM 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230.3.D for information regarding screening assessments.
- Please see CMS IOM 100-02, Chapter 15, Section 230.3.D for information regarding routine screening for hearing acuity or evaluations.
- 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.