Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27531

Speech-Language Pathology (SLP) Services: Communication Disorders

L27531

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

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.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Manual System, IOM Pub. 100-02 Medicare Benefit Policy Manual; IOM Pub. 100-03 Medicare National Coverage Determinations Manual, and IOM Pub 100-04, Medicare Claims Processing Manual.

CMS Publication, IOM 100-02, Medicare Benefit Policy Manual, Transmittal No. 88, Change Request #5921, May 7, 2008, describes Therapy Personnel Qualifications and Policies Effective January 1, 2008.

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

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

This LCD provides guidelines for selected speech-language pathology (SLP) services for communication disorders. This LCD does not address all SLP services. Please see LCD #L27537, Speech-Language Pathology (SLP) Services: Dysphagia; Includes VitalStim^® Therapy. 

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.

In order for SLP services to be considered reasonable and necessary, the following conditions must be met:

• The services must meet accepted standards of practice and be a specific and effective treatment for the patient’s condition;
• The services must be at a level of complexity, which can be safely and effectively performed only by a qualified SLP;
• There must be an expectation that the patient’s condition will improve significantly in a reasonable (and generally predictable) period of time, or the services must be necessary to the establishment of a safe and effective maintenance program; and
• The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.

A maintenance program consists of activities that preserve the patient's present level of function and prevent regression of that function. During the last visits for rehabilitative treatment, it may be reasonable and medically necessary for the clinician to develop a maintenance program, and instruct the patient, family member(s) or caregiver(s) in carrying out the maintenance program. Therapy performed repetitively to maintain a level of function is not eligible for reimbursement.

SLP EVALUATION AND DIAGNOSTIC SERVICES

Medicare provides reimbursement for an evaluation that is reasonable and necessary for the clinician to determine if there is an expectation that the services will be appropriate for the patient’s condition. 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. During the first patient contact, the clinician evaluates and documents:

• A diagnosis (where allowed) and description of the specific problem to be evaluated and/or treated. This should include the specific body area(s) evaluated. Include all conditions and complexities that may impact the treatment. A description might include, for example, the pre-morbid function, date of onset, and current function;
• Objective measurements, preferably standardized patient assessment instruments and/or outcomes measurement tools related to current functional status, when these are available and appropriate to the condition being evaluated;
• Clinician’s clinical judgments or subjective impressions that describe the current functional status of the condition being evaluated, when they provide further information to supplement measurement tools; and
• A determination that treatment is not needed, or, if treatment is needed a prognosis for return to pre-morbid condition or maximum expected condition with expected time frame and a plan of care.

A re-evaluation is the re-assessment of the patient’s performance and goals, after an intervention plan has been instituted, in order to determine the type and amount of change in treatments if needed. A re-evaluation may be indicated during an episode of care when a significant improvement, decline, or change in the patient's condition occurs. Re-evaluation requires the same professional skill as evaluation.

The decision to provide a re-evaluation shall be made by the clinician 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. Re-evaluations are usually focused on the current treatment and may not be as extensive as initial evaluations. Re-evaluations may be appropriate at a planned discharge.

Continuous assessment of the patient’s progress is a component of ongoing therapy services, and is not 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. Infrequent re-evaluations of maintenance programs may be covered when deemed necessary, if they require the skills of the SLP, and they are a distinct and separately identifiable service which can only be done safely by the SLP.

Current Procedural Terminology does not define a re-evaluation code for speech language pathology; the evaluation code should be used. The documentation should differentiate between evaluation/re-evaluation and screening. Screening assessments are noncovered and should not be billed.

Speech/hearing evaluation (CPT code 92506)

In addition to the general information above, 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. Please see the newly published update, CR#5921, referenced in the CMS National Coverage Policy section, above, for further details. One portion of the instruction is shown below:

“Assessment for the need for rehabilitation of the auditory system (but not the vestibular system) may be done by a speech language pathologist. Examples include but are not limited to: evaluation of comprehension and production of language in oral, signed, or written modalities, speech and voice production, listening skills, speech reading, communications strategies, and the impact of the hearing loss on the patient/client and family. [Later in the next paragraph it continues:] In determining the necessity for treatment, the beneficiary's performance in both clinical and natural environment should be considered.”

Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech (CPT code 92597)

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

Evaluation of patient for prescription of speech-generating devices (CPT codes 92607, 92608)

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 (e.g. words, pictures, and vocalizations). Includes evaluation of the ability to operate and effectively use a speech generating device or aid.

Assessment of Aphasia (CPT 96105)

This includes 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. Monthly or regular re-evaluations conducted to determine or document progress, e.g., Western Aphasia Battery, for a patient undergoing a restorative SLP program, are to be considered a part of the treatment session and would not be covered as a separate evaluation for billing purposes. For patients with severe aphasia, comprehensive assessments such as those listed above would not be performed routinely without documentation explaining the need.

Developmental testing; limited (CPT code 96110)

This includes screening/observations of cognitive abilities, gross and fine motor abilities and communication abilities necessary for performing daily activities, with interpretation and report.

Developmental testing; extended (CPT code 96111)

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

Standardized cognitive performance testing (CPT code 96125)

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 (CPT code 92507)

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. Regarding speech generating devices, use CPT code 92607 for selection and prescription; use CPT code 92609 for adaptation and training
   
   

4. Establishing effective use of appropriate prosthetic/adaptive devices for speaking

5. Providing rehabilition services for the auditory system, and related counseling services to individuals with heariing loss and to their family members/caregivers. Please see the newly published update, CR#5921, referenced in the CMS National Coverage Policy section, above, for further details. One portion of the instruction states: “Examples of rehabilitation include but are not limited to 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.”

6. Providing interventions for individuals with central auditory processing disorders; and /or

7. 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 speech-language pathologist. The patient is seen for sizing, fitting, placement or replacement and training of the voice prosthetic.

Speech/hearing therapy (group) (CPT code 92508)

For the purpose of performing group therapy, a group is defined as two to four patients receiving active therapy, but not one-on-one treatment; and the patients may be performing the same therapy, or a different therapy, but the speech-language pathologist is instructing all the patients in the group.

Group therapy services are rendered under an individualized plan of care, and are integral to the achievement of the patient’s individualized goals. Further, the skills of the SLP are required to safely and/or effectively carry out the group services; the group therapy satisfies all of the “reasonable and necessary criteria” listed under Indications and Limitations of Coverage and; group therapy accounts for no more than 25% of the patient’s total time in therapy.

Generally, social or support groups such as “stroke clubs” or “lost cord clubs” are not reimbursable.

Note: Regardless of the therapy being performed, if the patient is not receiving direct one-on-one contact, but is being supervised by the therapist, the group therapy code should be used.

Therapeutic services (patient adaptation and training) for the use of speech-generating devices (CPT code 92609)

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 function through the application of clinical skills and/or services. Use of these procedures requires that the therapist have direct (one-on-one) patient contact. Common components included as part of the therapeutic procedures include chart reviews for treatment, set up of activities and the equipment area, and review of previous documentation as needed. Also included is communication with other health care professionals, discussions with family, and calls to the referring physician for additional information or clarification. Subsequent to providing the therapeutic service, the treatment is recorded, and typically the progress is documented.

Therapeutic exercises and therapeutic activities are examples of therapeutic interventions. The expected goals must be documented in the treatment plan, and affected by the use of each of these procedures, in order to define whether these procedures are reasonable and necessary. Therefore, since one, or a combination of more than one of these modalities may be used in the treatment plan, documentation must support the use of each treatment or modality as it relates to a specific therapeutic goal.

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

Therapeutic exercises (CPT code 97110)

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 (CPT code 97530)

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.

In order for therapeutic activities to be covered, all of the following requirements must be met: the patient has a condition for which therapeutic activities can reasonably be expected to restore or improve functioning; the patient’s condition is such that he/she is unable to perform therapeutic activities except under the direct supervision of a clinician; and there is a clear correlation between the type of exercise performed and the patient’s underlying functional deficit(s) for which the therapeutic activities were prescribed.

Cognitive skills development (CPT code 97532)

This code describes interventions used to improve 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.

As stated earlier, speech-language pathology services are covered when performed with the expectation of restoring the patient's level of function which has been lost or reduced by injury or illness. There must be an expectation that the patient’s level of function will be restored, or significantly improved, in a reasonable (and generally predictable) period of time. When these interventions are used in the setting of chronic, generally progressive, cognitive disorders, there must be a potential for restoration or improvement of function. Therapy performed repetitively to maintain a level of function is not eligible for reimbursement.

Sensory integrative techniques (CPT code 97533)

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. When a patient has a deficit in processing input from a sensory system (e.g., vestibular, proprioceptive, tactile), it may decrease the patient’s ability to make adaptive sensory, motor, and behavioral responses to environmental demands. An example is a patient with several oral problems secondary to a stroke; the sensory integrative techniques used to facilitate speech might include icing or brushing techniques.

Self-care/home management training (CPT code 97535)

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. The patient must have a condition for which training in activities of daily living is reasonable and necessary, and such training must be reasonably expected to restore or improve the functioning of the patient. Documentation is expected to support the ability of the patient and/or caregiver to learn and retain instruction. Absence of such documentation may result in a denial of services. If the patient has questionable cognitive skills, a brief cognitive-communication assessment should be performed in order to establish the patient's learning ability.

This procedure is reasonable and necessary only when it requires the skills of a clinician, is designed to address specific needs of the patient, and is part of an active treatment plan directed at a specific outcome. Documentation must relate the training to expected functional goals that are attainable by the patient.

Coverage Limitations

Therapy performed repetitively to maintain a level of function is not eligible for reimbursement. Screening assessments are noncovered and should not be billed. Generally, social or support groups such as “stroke clubs” or “lost cord clubs” are not reimbursable. For patients with severe aphasia, comprehensive aphasia assessments would not be performed routinely without documentation explaining the need.

Examples of Unskilled Procedures: These services do not require the skills of a SLP and are not covered by Medicare. These include: Non-diagnostic/non-therapeutic routine, repetitive and reinforced procedures, e.g., the practicing of word drills without skilled feedback; procedures that are repetitive and/or reinforcing of previously learned material which the patient or family is instructed to repeat; procedures that may be effectively carried out with the patient by any nonprofessional, e.g., family member or restorative nursing aide after instruction and training is completed; and supervision of the patient practicing the use of augmentative or alternative communication systems.

Routine screening for hearing acuity or evaluations aimed at the use of hearing aids are not considered covered services. Therapy services and supplies directed toward the operation, use, maintenance or management of a hearing aid or other amplification device are excluded under §1862 (a)(7) of the Social Security Act, which prohibits coverage of any expenses incurred for items or services where such expenses are for hearing aids or examinations.

Outpatient Hospital Services; Physical, Occupational and Speech Therapy; Skilled Nursing Facility Care

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and 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 record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.
   
   
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 "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy for additional guidelines pertaining to the documentation requirements for the individual treatments/modalities.
   
   
7. Services will be denied if the medical record does not clearly indicate that the service that was billed was performed as per the CPT description, Indications and Limitations noted in this policy, the guidelines noted in the Documentation Requirements section of this policy and as per community standards of practice. Procedure codes that require supervision and/or time documentation will be denied if the medical record does not clearly support these services as billed.

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

American Speech-Language Hearing Association. (2001). Guidelines for Medicare coverage of speech-language pathology services.

DynCorp Therapy PSC Protocol

Guide to Physical Therapist Practice

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27531

05/22/2008

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