Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Speech Therapy
Policy #:MA10.007c

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

MEDICALLY NECESSARY


SPEECH THERAPY EVALUATION AND SERVICES RELATED TO SPEECH THERAPY
Speech therapy (speech language pathology [SLP]) evaluation and diagnostic services, therapeutic services, and/or therapeutic procedures are considered medically necessary and, therefore, covered when all of the following general criteria are met:

  • The services must meet accepted standards of practice and be a specific and effective treatment for the individual’s condition. Acceptable practices for therapy services are found in:
    • Medicare manuals
    • Local coverage determinations
    • Guidelines and literature of the profession of SLP
  • The services must be at a level of complexity that can be safely and effectively performed only by a qualified speech language pathologist (SLP).
  • The individual requires skilled speech therapy services in order to improve his/her current condition; maintain his/her current condition; or prevent or slow further deterioration of his/her condition. Coverage does not turn on the presence or absence of potential for improvement from therapy but rather on the individual's need for skilled care.
    • While an individual's particular medical condition is a valid factor in deciding if skilled therapy services are needed, an individual's diagnosis or prognosis cannot be the sole factor in deciding that a service is skilled or not skilled. The key issue is whether the skills of an SLP are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel or caregivers. Services that do not require the performance of an SLP are not skilled and are not medically necessary services, even if they are performed by a qualified professional. If a service can be self-administered or safely and effectively furnished by an unskilled person, without the direct or general supervision of an SLP, the service cannot be regarded as a skilled therapy service.
  • The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.
  • The below requirements for SLP evaluation and diagnostic services, therapeutic services, and/or therapeutic procedures are followed.

SLP EVALUATION AND DIAGNOSTIC SERVICES
SLP evaluation and diagnostic services are considered medically necessary and, therefore, covered in order for the SLP to determine if there is an expectation that the SLP services will be appropriate for the individual's condition. The evaluation of a individual's level of function is focused on identifying what the individual wants and needs to do and on identifying those factors that help or hinder the performance of those activities. During the first individual contact, the clinician evaluates and documents all of the following:
  • 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. Included are 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 individual assessment instruments and/or outcomes measurement tools related to current functional status, when these are available and appropriate to the condition being evaluated.
  • The SLP’s clinical judgments or subjective impressions describing the current functional status of the condition being evaluated, when such judgments or impressions provide further information to supplement measurement tools.
  • 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.
  • The evaluation or diagnostic service is appropriately utilized, following the guidelines listed for each of the evaluation or diagnostic services below.

Speech/Hearing Evaluation

A speech/hearing 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).

The evaluation of speech/hearing evaluation for disorders of the auditory system may also be considered as evaluation services (e.g., auditory processing evaluation). Assessment of the need for rehabilitation of the auditory system (but not the vestibular system) may be performed by an SLP. 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, communication strategies, and the impact of the hearing loss on the individual and family. In determining the necessity for treatment, the individual's performance in both the clinical and natural environments should be considered.

Evaluation for Use and/or Fitting of Voice Prosthetic Device to Supplement Oral Speech

The evaluation for use and/or fitting of voice prosthetic device to supplement oral speech includes the selection of a standard or indwelling voice prosthesis, determination of appropriate size prosthesis, and fitting a tracheostomy valve, including instructions for care and cleaning.

Evaluation for Prescription of Speech-Generating Devices

The evaluation for the prescription of speech-generating devices includes the evaluation of the individual's language comprehension and production across modalities (written, spoken, gestural) and the ability of the individual to operate and effectively use a speech-generating device or aid. The evaluation may also include evaluation of motor skills and nonverbal communication strategies (e.g. words, pictures, and vocalizations).

Assessment of Aphasia

The assessment of aphasia includes the assessment of the individual's 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 individual 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 individuals with severe aphasia, comprehensive assessments such as those listed above would not be performed routinely without documentation explaining the need.

Extended Developmental Test Administration

The developmental test administration includes the assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments. It also includes the interpretation and report.

Standardized Cognitive Performance Testing

Standardized cognitive performance testing 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 individual's performance/ability to complete tasks or demonstrate knowledge of a specific topic).

Evaluation of Oral and Pharyngeal Swallowing Function

The evaluation of oral and pharyngeal swallowing function is considered medically necessary and, therefore, covered for the evaluation of dysphagia, regardless of the presence of a communication disability.

Speech/Hearing Re-Evaluation

A speech/hearing re-evaluation is considered medically necessary and, therefore, covered during an episode of care when a significant improvement, decline, or change in the individual's condition occurs. A re-evaluation is the re-assessment of the individual’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. Re-evaluation requires the same professional skill as evaluation. The decision to provide a re-evaluation shall be made by the SLP 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 individual’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 medically necessary and, therefore, covered when deemed necessary, if they require the skills of the SLP, and they are a distinct and separately identifiable service that can only be provided safely by the SLP.

SLP THERAPEUTIC SERVICES
Speech/Hearing Therapy

SLP 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 are considered medically necessary and, therefore, covered for any of the following:
  • Provision of consultation, counseling, and make referrals when appropriate
  • Provision of training and support to family members/caregivers and other communication partners of individuals with speech, voice, language, communication, fluency and hearing disabilities
  • Development and establishment of effective augmentative and alternative communication techniques and strategies, including selecting, prescribing and dispensing of aids and devices and training individuals, their family members/caregivers, and other communication partners in their use.
    • For speech generating devices, use CPT code 92607 for selection and prescription and use CPT code 92609 for adaptation and training
  • Establishment of the effective use of appropriate prosthetic/adaptive devices for speaking
  • Provision of rehabilitation services for the auditory system, and related counseling services to individuals with hearing loss and to such individual's family members/caregivers. Examples 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.
  • Provision of interventions for individuals with central auditory processing disorders
  • Modification or training in use of a voice prosthetic. A modification of a voice prosthetic to supplement oral speech would be appropriate and should be carried out by an SLP. The individual is seen for sizing, fitting, placement or replacement and training of the voice prosthetic.

In addition, when any of the following SLP therapeutic services are provided, the requirements outlined for each service must be met:

Group Speech/Hearing Therapy
For the purpose of performing group therapy, a group is defined as two to four individuals receiving active therapy, but not one-on-one treatment; the individuals may be performing the same therapy, or a different therapy, but the SLP is instructing all the individuals in the group.

Group therapy services are rendered under an individualized plan of care and are integral to the achievement of the individual’s goals. The skills of the SLP required to safely and/or effectively carry out the group services and group therapy account for no more than 25 percent of the individual’s total time in therapy.

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

Therapeutic Services (Patient Adaption and Training) for the Use of Speech-Generating Devices
Individual adaptation and training for the use of speech-generating devices includes the development of operational competence in using a speech-generating device or aids, including customizing the features of the device to meet the specific communication needs of each individual and providing opportunities for developing skills in all aspects of device use.

SLP THERAPEUTIC PROCEDURES
Therapeutic procedures are considered medically necessary and, therefore, covered as treatments that attempt to reduce impairments and improve function through the application of clinical skills and/or services. Following are the requirements for the use of therapeutic procedures:
  • Use of these procedures requires that the therapist have direct (one-on-one) individual 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 healthcare professional for additional information or clarification. Subsequent to providing the therapeutic service, the treatment is recorded, and typically the progress is documented.
  • The expected goals must be documented in the treatment plan, and effected by the use of each of these procedures, in order to define whether these procedures are medically 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.

In addition, when any of the following SLP therapeutic procedures are provided, the requirements outlined for each service must be met:

Cognitive Skills Development

Cognitive skills development describes interventions used to improve cognitive skills (e.g., attention, memory, problem solving) with direct (one-on-one) individual contact by the SLP. Cognitive skills development may be medically necessary for individuals with acquired cognitive impairments from head trauma, acute neurological events (including cerebrovascular accidents), or other neurological disease.

Treatment of Swallowing Dysfunction and/or Oral Function for Feeding

The treatment of swallowing dysfunction and/or oral function for feeding is considered medically necessary and, therefore, covered for the treatment of dysphagia, regardless of the presence of a communication disability.

NOT COVERED

Social or support groups such as “stroke clubs” or “lost cord clubs” are not covered by the Company because they are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

The following services services are not covered by the Company because they are not covered by Medicare. These services do not require the skills of an SLP. Therefore, they are not eligible for reimbursement consideration.
  • 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 that the individual or family is instructed to repeat
  • Procedures that may be effectively carried out with the individual by any nonprofessional (e.g., family member) after instruction and training is completed
  • Supervision of the individual 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 covered by the Company because they are services not covered by Medicare. Therefore, they are not eligible for reimbursement consideration. Therapy services and supplies directed toward the operation, use, maintenance, or management of a hearing aid or other amplification device are not covered and, therefore, are not eligible for reimbursement consideration.

Developmental screening is considered a screening service and is not covered by the Company because it is a service not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.


NOT MEDICALLY NECESSARY

Services provided concurrently by different types of clinicians (e.g., SLPs, occupational therapists) may be covered if separate and distinct goals are documented in the treatment plans. For example, when individuals are receiving both occupational and speech therapy, or speech therapy with different providers, the therapies must provide different treatments with separate treatment plans and goals in order for each to be covered and be separately reimbursed. Otherwise, the therapy is considered duplicate therapy that is not medically necessary and, therefore, not covered.


EXPERIMENTAL/INVESTIGATIONAL

Transcutaneous neuromuscular electrical stimulation for the treatment of dysphagia, (e.g. VitalStim® therapy) is considered experimental/investigational and, therefore, not covered for the treatment of individuals with dysphagia. Because the code for dysphagia treatment (CPT code 92526) is a comprehensive code that includes all treatment approaches, payment may be made for other medically necessary dysphagia treatments.


MAINTENANCE THERAPY

MEDICALLY NECESSARY
Maintenance therapy consists of activities that preserve the individual's level of function or prevent regression of that function. Maintenance begins when the therapeutic goals of a plan of care have been achieved or when no further progress is apparent or expected to occur.

Maintenance therapy is considered medically necessary and therefore, covered when the specialized skill, knowledge and judgement of a qualified professional is required to establish, instruct and carry out a program to maintain the individual's current condition or to prevent or slow further deterioration.

Documentation with objective evidence or a clinically supportable statement is needed to support the necessity of the skilled services provided and the individual's response to treatment.

NOT MEDICALLY NECESSARY
Maintenance therapy is considered not medically necessary, and therefore not covered in the following circumstances when the professional skills of a qualified professional are not required:
  • Therapies after the individual has achieved therapeutic goals
  • Therapy services performed by the individual alone or with the assistance of a family member or unskilled caregiver


REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

When ongoing speech therapy treatment is being requested, documentation from the initial evaluation should include all of the following:
  • A diagnosis and description of the specific problem to be treated. This should include the specific body area(s) evaluated and all conditions and complexities that may impact treatment. For example, a description should include the pre-morbid function, date of onset, and current level of function.
  • Objective measurements, preferably standardized patient assessment instruments, and/or outcomes measurement tools related to current functional status, when available and appropriate to the condition being evaluated.
  • Clinician's clinical judgments or subjective impressions describing the current functional status of the condition being evaluated, when such judgments and impressions provide further information to supplement measurement tools.
  • A prognosis for return to pre-morbid condition or maximum expected condition with expected time frame and measurable plan of care.

The medical record should include the plan of care that has been written and developed by the eligible professional provider. The plan of care must be established prior to the initiation of therapy and signed by the provider.

The plan of care should include the following information:
  • The individual's significant history
  • The individual's diagnoses that require therapy
  • Any related orders
  • The goals for therapy, which should be specific and measurable, and the expected potential for achievement, which should include the type, amount, duration, and frequency of therapy services
  • Any contraindications to a course of therapy
  • The individual's awareness and understanding of the diagnoses, prognoses, and goals of therapy
  • The development of a maintenance program while therapy is being provided
  • When appropriate, a summary of past therapies and the results that were achieved

Daily treatment notes should include the following information:
  • Date of treatment
  • Specific treatment provided
  • Response to treatment
  • Skilled ongoing reassessment of the individual’s progress towards established goals
  • Objective, measurable, and specific documentation of progress towards goals using consistent and comparable methods
  • Changes to plan of care or objective reasoning for why the individual has not progressed towards goals
  • Name and credentials of the treating clinician

Policy Guidelines

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, speech language pathology (SLP) services are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met. However, services that are identified in this policy as experimental/investigational or not covered are not eligible for coverage or reimbursement by the Company.

BILLING GUIDELINES

Speech therapy sessions are service-based codes, not time-based codes. Therefore, these services are reported and reimbursed based on the service provided, not the duration of the service. Providers should report a single encounter with "1" as the unit of service, regardless of the duration of the service on a given day.


Description

Speech therapy (speech/language pathology) services are services that are deemed necessary for the diagnosis and/or treatment of speech disorders, language disorders, and cognitive communication impairments that result in communication disabilities or dysphagia (swallowing disorder). Speech therapy is the medically prescribed treatment for speech and language disorders due to disease, surgery, injury, congenital anomalies (e.g., congenital hearing impairment), speech/language delay, or previous therapeutic processes that result in communication disabilities and/or dysphagia. Speech/language pathologists use a variety of modalities in the treatment of communication deficits and dysphagia, allowing for successful treatment outcomes.

TRANSCUTANEOUS NEUROMUSCULAR ELECTRICAL STIMULATION (NMES) FOR THE TREATMENT OF DYSPHAGIA

VitalStim® is a type of neuromuscular electrical stimulation therapy for the treatment of dysphagia, which uses small electrical currents to stimulate the muscles responsible for swallowing. VitalStim® is used in conjunction with traditional dysphagia treatment of oromotor exercises, and swallowing strategies.

Based upon review of the scientific and clinical literature, the clinical efficacy and clinical utility of this service remains unproven. Recent studies with the use of this surface electrical stimulation treatment show a lowering of the hyoid bone during swallowing, which may actually be harmful to the individual.
References

American Speech-Language-Hearing Association (ASHA). 2020 ICD-10-CM diagnosis codes related to speech, language, and swallowing disorders. [ASHA Web Site]. 2019. Available at: https://www.asha.org/uploadedFiles/ICD-10-Codes-SLP.pdf.

American Speech-Language-Hearing Association (ASHA). Medicare guidelines for group therapy. Speech-language pathology services. [ASHA Web Site]. 2019. Available at: https://www.asha.org/practice/reimbursement/medicare/grouptreatment/.

American Speech-Language-Hearing Association (ASHA). New and revised speech language pathology ICD-10-CM codes for 2020. [ASHA Web Site]. 2019. Available at: https://www.asha.org/Practice/reimbursement/coding/New-and-Revised-ICD-10-CM-Codes-for-SLP/.

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered Medical and Other Health Services. §220: Coverage of Outpatient Rehabilitation Services (Physical Therapy, Occupational Therapy, Speech-Language Pathology Services) Under Medical Insurance . [CMS Web site]. 07/01/19. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed July 12, 2019.

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered Medical and Other Health Services. §230: Practice of Speech-Language Pathology. [CMS Web site]. 02/01/19. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed July 12, 2019.

Centers for Medicare. National Coverage Determination (NCD) for Speech-Language Pathology Services for the Treatment of Dysphagia (170.3). 10/01/2006 [CMS website]. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=192&ncdver=2&bc=AAAAgAAAAAAAAA%3d%3d&. Accessed July 12, 2019.
Evidence of Coverage.

Novitas Solutions, Inc. Local Coverage ArticleA54111. Billing and Coding: Speech language pathology (SLP) services: communication disorders. [Novitas Solutions, Inc. Web site]. 10/31/2019. Available at:https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54111&ver=23&name=331*1&UpdatePeriod=857&bc=AAAAEAAAAAAA&. Accessed November 4, 2019.

Novitas Solutions, Inc. Local Coverage ArticleA57656. Billing and Coding: Speech-language pathology (SLP) services: dysphagia; includes Vitalstim therapy. [Novitas Solutions, Inc. Web site]. 10/31/2019. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=57656&ver=6&name=331*1&UpdatePeriod=857&bc=AAAAEAAAAAAA&. Accessed November 4, 2019.

Novitas Solutions, Inc. Local Coverage Determination (LCD) L35070: Speech-language pathology (SLP) services: communication disorders. [Novitas Solutions, Inc. Web site]. 10/01/2015. 10/31/2019. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35070&ver=69&Date=07%2f12%2f2019&SearchType=Advanced&DocID=L35070&bc=KAAAABgAAAAA&Accessed November 4, 2019.

Novitas Solutions, Inc. Local Coverage Determination (LCD) L34891: Speech-language pathology (SLP) services: dysphagia; includes VitalStim® therapy. [Novitas Web site]. 10/01/2015. Revised 03/29/2018. Available at:https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34891&ver=28&name=331*1&UpdatePeriod=857&bc=AAAAEAAAAAAA&. Accessed November 4, 2019.

US Food and Drug Administration (FDA). Centers for Devices and Radiological Health (CDRH). eSWALLOW™ Dysphagia Therapy Unit. 510(k) summary. [FDA Web site]. 02/10/2011. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf9/K092202.pdf. Accessed July 12, 2019.

US Food and Drug Administration (FDA). Centers for Devices and Radiological Health (CDRH). Guardian Dysphagia dual channel NMES unit. 510(k) summary. [FDA Web site]. 02/07/2013. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf12/K120922.pdf. Accessed July 12, 2019.

US Food and Drug Administration (FDA). Centers for Devices and Radiological Health (CDRH). VitalStim® Plus Electrotherapy System. 510(k) summary. [FDA Web site]. 02/17/2016. Available at:https://www.accessdata.fda.gov/cdrh_docs/pdf15/k153224.pdf. Accessed July 12, 2019.

US Food and Drug Administration (FDA). Centers for Devices and Radiological Health (CDRH). Vtitalstim-Experia. 510(k) summary. [FDA Web site]. 06/11/2007. Available at:https://www.accessdata.fda.gov/cdrh_docs/pdf7/K070425.pdf. Accessed July 12, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

THE FOLLOWING CODES ARE MEDICALLY NECESSARY AND, THEREFORE, COVERED:


92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92607, 92608, 92609, 92610, 96105, 96112, 96113, 96125, 97129, 97130

THE FOLLOWING CODE IS NON-COVERED:

96110



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Report any applicable diagnosis that meets the medical necessity criteria in this policy.


HCPCS Level II Code Number(s)



MEDICALLY NECESSARY

G0153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes

G0161 Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language therapy maintenance program, each 15 minutes

S9128 Speech therapy, in the home, per diem

S9152 Speech therapy, re-evaluation



Revenue Code Number(s)



0440 General classification for speech-language pathology

0441 Speech-language pathology charge by visit

0442 Speech-language pathology hourly charge

0443 Speech-language pathology group rate

0444 Speech-language pathology evaluation or re-evaluation

0449 Other speech-language pathology services

0979 Professional fees - speech pathology



Misc Code

Modifier(s):


TO REPORT HABILITATION OR REHABILITATION SERVICES, APPEND THE FOLLOWING MODIFIERS:

96 Habilitative Services
97 Rehabilitative Services



Coding and Billing Requirements






Policy History

MA10.007c
01/01/2020The version of this policy will become effective 01/01/2020.

This policy has been updated in consideration of existing Evidence of Coverage revisions for Maintenance Therapy.

The following CPT code has been termed from this policy: 97127.
The following HCPCS code has been termed from this policy: G0515.
The following CPT codes have been added to this policy: 97129 and 97130.


Revisions from MA10.007b:
01/01/2019Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

This policy has been identified for the CPT code update, effective 01/01/2019.

The following CPT code has been deleted from this policy: 96111

The following CPT codes have been added to this policy: 96112, 96113

Revisions from MA10.007a:
09/26/2018This policy has been reviewed and reissued to communicate the Company’s continuing position on Speech Therapy.
01/01/2018This policy has been identified for the CPT / HCPCS code update, effective 01/01/2018.

The following CPT code has been termed from this policy:

97532 Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

The following CPT, HCPCS codes have been added to this policy

97127 Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact

G0515 Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

Revisions from MA10.007
05/24/2017This policy has been reviewed and reissued to communicate the Company’s continuing position on speech therapy.
04/13/2016This policy has been reviewed and reissued to communicate the Company’s continuing position on Speech Therapy.
04/15/2015This policy has been reviewed and reissued to communicate the Company’s continuing position on Speech Therapy.
01/01/2015This is a new policy.

Note: On 12/23/2014, this policy was identified for CPT code update, effective 01/01/2015.
The following CPT narrative has been revised in this policy:96110





Version Effective Date: 01/01/2020
Version Issued Date: 12/30/2019
Version Reissued Date: N/A