Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Speech Therapy

Policy #:10.06.01k

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

MEDICALLY NECESSARY

SPEECH THERAPY EVALUATION AND SERVICES RELATED TO SPEECH THERAPY
Speech therapy evaluation and services related to speech therapy that are within the scope of the member's benefit contract are considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The evaluation (92521-92524) is performed by a speech/language pathologist who is licensed in the state where the services are being performed and who is certified by the American Speech-Language-Hearing Association (ASHA).
    • The documentation submitted must include a current comprehensive diagnostic evaluation that was performed within three months of the requested start date of the therapy. [Note: Refer to the Required Documentation section for more information.]
  • The services must be of such a complex nature that they can only be performed by a speech/language pathologist.
  • The condition must be such that there is a reasonable expectation that the services will bring about a significant improvement within a reasonable time frame, regardless of whether the individual has a coexisting disorder.
  • The services are provided in accordance with an ongoing plan of care specific to the diagnosis.
    • The plan of care should incorporate ongoing care and be updated at least weekly, or more frequently as treatment progresses and goals change or are met. Upon request, documentation must be made available to the Company to show measurable progress toward meeting the short- and long-term goals outlined in the plan of care.
    • The therapy is performed for a communication disorder that is a result of at least one of the following:
      • Disease (e.g., Parkinson's disease) resulting in increased difficulty in swallowing and/or speaking
      • Surgery (e.g., surgical removal of a malignant growth on the head or neck)
      • Injury (e.g., automobile accident resulting in a subdural hematoma influencing the speech center causing neurogenic stuttering; aphasia following a cerebrovascular accident [CVA])
      • Congenital anomalies (e.g., inborn defect of the skull, cleft lip, cleft palate, congenital hearing impairment)
      • Speech/language delay that is developmental in nature (i.e., speech and/or language skills are below the normal range of developmental milestones for the age of the individual as determined by age-appropriate standardized test data)
  • The amount, frequency, and duration of the services must be consistent with accepted standards of practice.
OR
  • The evaluation (assessment) (92610) and therapy is performed for a swallowing disorder (dysphagia) resulting from a condition such as, but not limited to, a CVA, regardless of whether a communication disorder also exists.

EVALUATION FOR PRESCRIPTION OF SPEECH-GENERATING DEVICES (CPT CODES 92607, 92608)
  • 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).

SPEECH THERAPY RE-EVALUATION
  • A re-evaluation (S9152) is the reassessment of the individual’s performance and goals, after a plan of care has been instituted. A re-evaluation is considered medically necessary and, therefore, covered when a significant improvement, decline, or change in the individual's condition occurs, or if it is requested by the Company to determine the medical necessity of ongoing intervention. A re-evaluation requires the same professional skill as evaluation. A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making professional judgment about continued care, modifying goals, and/or treatment or terminating services.

THERAPEUTIC SERVICES (PATIENT ADAPTATION AND TRAINING) FOR THE USE OF SPEECH-GENERATING DEVICES (CPT CODE 92609)
  • 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.

NOT MEDICALLY NECESSARY

CONDITIONS THAT DO NOT MEET MEDICAL NECESSITY CRITERIA
Speech therapy services performed for reasons other than those listed above are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury. These conditions or situations include, but are not limited to, the following:
  • Psychosocial speech delay (Psychosocial factors can be associated with delayed speech development. These factors include, but are not limited to, large family size, late birth order, twinship, bilingual background.)
  • Behavior/social problems (e.g., impulsive behavior, difficulty in initiating/maintaining a conversation)
  • Stammering and stuttering that was not caused by acquired brain injury
  • Programs that are primarily educational in nature or that support an academic program
  • Services that otherwise would not require the skills of a qualified speech/language pathologist such as treatments that maintain function by using routines and repetitions
    • Examples of these services include, but are not limited to, word drills for developmental articulation errors, computer-based programs, and procedures that may be performed by the individual, family, or caregivers.
  • Accent modification
  • Social or support groups (e.g., "stroke clubs" or "lost cord clubs")
  • Behavioral feeding issues (e.g., decreased food repertoire ["picky eater"]) when a swallowing disorder is not present or does not result in a medical condition (e.g., failure to thrive, delayed growth)

EXPERIMENTAL/INVESTIGATIONAL

MYOFUNCTIONAL THERAPY (OROFACIAL MYOFUNCTIONAL THERAPY)
Myofunctional therapy (orofacial myofunctional therapy) is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

TRANSCUTANEOUS NEUROMUSCULAR ELECTRICAL STIMULATION (NMES) FOR THE TREATMENT OF DYSPHAGIA
Although the US Food and Drug Administration (FDA) has approved devices for transcutaneous neuromuscular electrical stimulation for the treatment of dysphagia, the Company has determined that the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature. Therefore, transcutaneous neuromuscular electrical stimulation for the treatment of dysphagia is considered experimental/investigational by the Company and not covered.

DUPLICATE THERAPY
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 which is not medically necessary and, therefore, not covered.

BENEFIT CONTRACT EXCLUSIONS

COGNITIVE REHABILITATIVE THERAPY
Cognitive rehabilitative therapy is a benefit contract exclusion and is, therefore, not covered with the following exception:
  • When provided integral to other supportive therapies, such as, but not limited to, physical, occupational, and speech therapies in a multidisciplinary, goal-oriented, and integrated treatment program designed to improve management and independence following neurological damage to the central nervous system caused by illness or trauma (e.g., stroke, acute brain insult, encephalopathy)

MAINTENANCE THERAPY
For most of the Company's products, speech therapy for the maintenance of a chronic condition is not covered by the Company because it is a benefit contract exclusion. Therefore, for these products, it is not eligible for reimbursement consideration. Individual member benefits must be verified.
  • Maintenance therapy is defined as a continuation of care and management of the individual when the maximum therapeutic value of a treatment plan has been achieved, no additional functional improvement is apparent or expected to occur, and the provision of services for a condition ceases to be of therapeutic value.

BENEFIT LIMITATIONS

Limitations, frequency, and annual maximums may be applied and vary by product or by group.
Individual member benefits must be verified, as speech therapy benefits vary by product and group.

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.

Documentation must support the medical necessity for the performance of a speech therapy evaluation or re-evaluation. Routine performance of speech therapy evaluations or re-evaluations are subject to review by the Company.

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 include 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 that describe the current functional status of the condition being evaluated, when they 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

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, speech therapy is covered under the medical benefits of the Company products when the medical necessity criteria listed in this medical policy are met. However, services that are identified in this policy as not medically necessary, experimental/ investigational, or a benefit contract exclusion 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.

CAPITATION

In geographic regions with a capitated outpatient rehabilitation program, outpatient speech therapy services are not included in capitation.

MANDATES

This policy is consistent with applicable state mandates. The laws of the state where the group benefit contract is issued determine the mandated coverage.

Speech therapy services may be available for coverage in accordance with the New Jersey State Mandate for Biologically Based Mental Illness and the Pennsylvania State Mandate for Autism Spectrum Disorders (ASD).

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the FDA for transcutaneous neuromuscular electrical stimulation for the treatment of dysphagia.

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.

Speech therapy services can be habilitative or rehabilitative. Habilitation therapy refers to health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. These services are provided by or under the supervision of an organized staff of professional providers.

Rehabilitation therapy consists of treatments designed to improve, maintain, and prevent the deterioration of skills and functioning for daily living that have been lost or impaired. These services are provided by or under the supervision of an organized staff of professional providers.

MYOFUNCTIONAL THERAPY FOR TEMPOROMANDIBULAR DISORDERS

Myofunctional therapy (e.g., orofacial myofunctional therapy) is the treatment of an orofacial muscle imbalance, an incorrect swallowing pattern, temporomandibular joint muscle dysfunction syndrome, and/or tongue thrusting, bruxing, clenching, or sucking habits. Oral myofunctional therapy uses exercises and stimulation to increase awareness of oral and facial muscles and inhibit inappropriate oral behaviors and/or strengthen appropriate oral muscle functioning. This treatment implies metacognitve abilities of the individual, which include self-awareness and self-monitoring. Although the use of this treatment approach has yielded some positive results for some individuals exhibiting orofacial muscle imbalance, tongue thrusting and bruxing, the data collected thus far has been inconclusive regarding its true effectiveness.

Cai et al. (2010) evaluated the effectiveness of orofacial myofunctional therapy (OMT) on facial mimic muscles for individuals with incomplete peripheral facial injury. Ninety-two individuals with 241 injured branches of incomplete peripheral facial nerve injury were separated into a treatment and a control group and were followed for a range of 1 to 4 years. The treatment group consisted of 58 individuals. Outcome measurements included a House-Brackmann facial nerve grading system, a quantitative facial nerve function estimating system, and electroneurography. Based on these measurements, facial nerve injury was categorized as normal, minor, moderate, or severe. Among those with minor facial injury, there was no statistically significant difference in the time needed for initial recovery of nerve function following injury or for final recovery (i.e., time point after which no further improvement could be obtained) between the treatment and control groups. In the moderate and severe facial groups, both the initial recovery and final recovery was shorter for the OMT group than for the control group. The authors concluded that while OMT on facial mimic muscles may not shorten the recovery time for individuals with minor facial nerve injuries, it may accelerate the rate of recovery for individuals with moderate or several facial injury.

de Felicio et al. (2010) evaluated the effectiveness of OMT on the treatment of individuals with associated articular and muscular temporomandibular disorders (TMD). Ten individuals were treated with OMT (T group), 10 individuals were treated with an occlusal splint (OS group), and 10 individuals were untreated (control group). Additionally, there were 10 individuals without TMD who represented asymptomatic individuals. Outcome measurements included Helkimo Index symptom scores, frequency and severity of signs and symptoms, and orofacial myofunctional evaluation. The authors determined that individuals treated with OMT presented better results and had a statistically significant improvement when compared with those treated with an occlusal splint. The study is limited by its small sample size, particularly when considering the number of stratifications created by the authors for intergroup comparisons.

Ferreira et al. (2011) evaluated the available scientific literature on the effectiveness of OMT for the treatment of oral myofunctional disorders. Of 108 studies identified and published between 2000 and 2010, 38 were chosen for inclusion in the review. The included studies were primarily retrospective case series and literature reviews. The authors concluded that there was a lack of knowledge about the effects of myofunctional exercises used by clinicians. Additionally, there was a lack of scientific evidence about appropriate treatment protocols and indications for use.

The current available peer-reviewed literature and scientific evidence is insufficient in both quality and quantity to permit conclusions regarding the safety and effectiveness of OMT. There exist some studies that indicate that there may be symptom improvement in a select patient population. However, the majority of the available literature consists of case series with small sample size and short-term follow-up. Larger randomized controlled trials with appropriate follow-up and validated comparative control groups are necessary to determine the safety and effectiveness of OMT.

TRANSCUTANEOUS NEUROMUSCULAR ELECTRICAL STIMULATION (NMES) THERAPY FOR DYSPHAGIA

Devices such as, VitalStim® Experia (VitalStim®) involve electrotherapy treatment that is used by licensed health care providers, including speech therapists, for treating individuals who have dysphagia caused by any non-mechanical cause. VitalStim® therapy is a specialized type of neuromuscular electrical stimulation (NMES) in which a small current is passed through external electrodes on the neck to stimulate inactive or atrophied swallowing muscles. With repeated therapy, throat muscles are said to be retrained. However, based upon review of the scientific and clinical literature, the clinical efficacy and utility of this service remains unproven.

In 2007, Carnaby-Mann et al. conducted a meta-analysis aimed at evaluating the effect of transcutaneous neuromuscular electrical stimulation (NMES) on swallowing rehabilitation. The authors identified 7 publications (2 were controlled studies) which met inclusion/exclusion criteria, with a total patient population of 225 with swallowing difficulty from numerous etiologies (e.g., stroke, cancer etc.). Clinical swallowing scale was the only health outcome metric used across all included studies. Treatment protocols varied in length from one to 24 weeks, in total number of treatment sessions, and in regard to reporting of electrode placement. The authors reported a significant effect size with significant heterogeneity. Removal of two outlier trials rendered heterogeneity non-significant, although statistical testing supporting the classification of these trials as outliers was not presented. Based on the aforementioned results the authors concluded that this preliminary meta-analysis revealed a small but significant summary effect size for transcutaneous NMES for swallowing and noted the small number of studies and low methodological grading for these studies. The large methodological differences between study protocols and outcome measurements and NMES treatment methodologies precludes the discernment of any reliable conclusions from these data.

Ryu et al. (2008) published the results from a prospective, randomized, double blinded case-control study aimed at evaluating the effect of NEMS (VitalStim) on dysphagia following treatment for head and neck cancer. The study randomized 14 individuals to 30 minutes of NMES and 30 minutes of traditional swallowing training for 5 days per week for 2 weeks, with 12 individuals randomized to sham stimulation plus traditional swallowing training. Functional changes assessed by the clinical dysphagia scale (CDS), the functional dysphagia scale (FDS), the American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) and the M.D. Anderson dysphagia inventory (MADI) were the main outcomes assessed before and after treatment. The authors reported that average changes of FDS score were 11.4 ± 8.1 for the experimental group, and 3.3 ± 14.0 for the control group. No significant results were observed in regard to CDS, ASHA NOMS, and MADI scales. While noting limitations including but not limited to small sample size, participants lost to follow-up, and heterogeneity within study population, the authors concluded that the results suggest that the combination of electrical stimulation and conventional rehabilitation treatment is superior to conventional rehabilitation treatment alone in those suffering from dysphagia following treatment for head and neck cancer.

Lin et al. (2009) published results from a comparative study intended to assess the effectiveness of functional electrical stimulation (FES) (VitalStim) in comparison to a home rehabilitation program (HRP). The study enrolled 20 individuals with nasopharyngeal carcinoma. FES treatment consisted of 15 60-minute sessions of stimulation 1 to 3 times per week. The FES electrodes were placed above the hyoid bone and between the hyoid bone and thyroid cartilage to stimulate the supra-hyoid muscles. HRP subjects were instructed to perform twice-daily strengthening exercises and repeat each item more than 10 times during each session with follow-up every 2 weeks. Outcomes related to quality of life, the penetration–aspiration scale (PAS), the movement of the hyoid bone, and the amount of pyriform sinuses stasis were assessed before and after treatment. The authors observed improvements in quality of life, the duration of the movement of thin barium through the hyoid, and speed of paste barium through the hyoid. The pyriform sinus stasis area of the paste barium reached significant difference within the FES group. Conversely, no improvements in swallowing outcomes were reported in the HRP group. Also, the reported degree of improvement in the movement speed of the thin barium and the PAS of the paste barium were statistically significantly greater in the FES group than in the HRP group. Based on these results, the authors concluded that FES will improve the swallowing function of individuals with nasopharyngeal carcinoma with dysphagia and bring about better quality of life. While acknowledging a few limitations, the authors neglected to address the full limitations of a small sample size, its impact on statistical power, and the large probability for Type II statistical error. Additional methodological flaws were also not addressed, including the lack of a statistical adjustment (e.g., a bonferroni correction) commonly applied to the alpha value (p-value) when making multiple comparisons.

In 2009, Permsirivanich et al. (2009) published results from a randomized controlled trial which compared outcomes between NMES (VitalStim) and rehabilitation swallowing therapy (RST). The study randomized 23 individuals with stroke and persistent dysphagia to receive NMES or RST 11 for 4 weeks or until they reached functional oral intake scale (FOIS) level 7 (i.e., total oral diet with no restrictions). Outcomes were assessed as changes in functional oral intake (FOIS), complications associated with therapy, and number of therapy sessions. The authors reported an improvement FOIS functional oral intake by at least one unit compared to the prior-to-therapy score in 91.3% of all participants, 90.91% in the RST group and 91.67% in the NMES group. Also, a statistically significant difference in average changes in FOIS scores was also observed between groups.

The authors noted the positive effects of both treatments on persistent dysphagia while also calling for further investigation into the effects of NMES on specific biomechanical aspects of pharyngeal swallowing, as well as the best location for electrode adhesion, effects of varying frequencies and amplitude of electrical stimulation on swallowing physiology, duration of each session, total number of sessions due to the variable responses among individuals, and the need for larger studies to validate study results.

Xia et al. (2011) conducted a randomized, controlled three-armed trial intended to evaluated the effects of VitalStim therapy coupled with conventional swallowing training on the recovery of individuals that had dysphagia post-stroke. The study randomized 120 participants to one of three treatment arms: conventional swallowing therapy group, VitalStim therapy group, and VitalStim therapy plus conventional swallowing therapy group. Data regarding swallowing function (assessed by the Standardized Swallowing Assessment (SSA) and Videofluoroscopic Swallowing Study (VFSS) tests), swallowing-related quality of life (assessed by the SWAL-QOL questionnaire), and signals of surface electromyography (sEMG) of swallowing muscles were recorded prior to and following 4 weeks of treatment. Improvements in all treatment arms were observed following treatment in regard to functional and quality of life outcomes when compared to baseline. Intergroup comparisons of outcomes following treatment illustrated that combination therapy significantly improved outcome metrics over conventional therapy or VitalStim therapy alone. As noted in previous trials, no significant differences were found between the conventional swallowing therapy group and the VitalStim therapy group. Based on these results, the authors concluded that VitalStim therapy coupled with conventional swallowing training was conducive to recovery of post-stroke dysphagia, although the authors noted that studies evaluating the long-term effects of the both single and combination therapy methods are needed.
References


American Speech-Language-Hearing Association (ASHA). Accent modification. [ASHA Web site]. 2011. Available at: http://www.asha.org/public/speech/development/accent-modification/Accessed April 18, 2017.

American Speech-Language-Hearing Association (ASHA). Autism (practice portal). Available at: www.asha.org/Practice-Portal/Clinical-Topics/Autism/. Accessed April 18, 2017.

American Speech-Language-Hearing Association (ASHA). Roles of speech-language pathologists in swallowing and feeding disorders. [ASHA Web site]. 2002. Available at: http://www.allaboutkidsny.com/therapist_login/important/clinical/Swallowing%20and%20Feeding%20Disorders.pdf. Accessed July 09, 2018.

American Speech-Language-Hearing Association (ASHA). Stuttering. [ASHA Web site]. Available at: http://www.asha.org/public/speech/disorders/stuttering.htm. Accessed July 09, 2018.

Andrade CR, Juste FS. Systematic review of delayed auditory feedback effectiveness for stuttering reduction. J Soc Bras Fonoaudiol. 2011;23(2):187-191.

Cai ZG, Shi XJ, Lu XG, et al. Efficacy of functional training of the facial muscles for treatment of incomplete peripheral facial nerve injury. Chin J Dent Res. 2010;13(1):37-43.

Cantwell DP, Baker L. Assessment. In: Developmental Speech and Language Disorders. New York, NY: Guilford Press; 1987: 42.

Carter J, Musher K. Evaluation and treatment of speech and language disorders in children. [Up to Date Web site]. 09/28/2017. Available at: http://www.uptodate.com [via subscription only]. Accessed July 09, 2018.

Cayley AS, Tindall AP, Sampson WJ, Butcher AR. Electropalatographic and cephalometric assessment of myofunctional therapy in open-bite subjects. Aust orthod J. 2000;16(1):22-33.

Clark DG. Aphasia: prognosis and treatment. [Up to Date Web site]. 02/18/2018. Available at: http://www.uptodate.com. Accessed July 09, 2018.

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Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 170.3: Speech-language pathology services for the treatment of dysphagia. [CMS Web site]. 10/01/2006. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=192&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed July 09, 2018.

Christensen M, Hanson M. An investigation of the efficacy of oral myofunctional therapy as a precursor to articulation therapy for pre-first grade children. J Speech Hear Disord.1981;46(2):160-165.

Company Benefit Contracts.

De Félicio CM, Freitas RL, Bataglion C. The effects of orofacial myofunctional therapy combined with an occlusal splint on signs and symptoms in a man with TMD-hypermobility: case study. Int J Orofacial Myology. 2007;33:21-9.

De Felício CM, de Oliveira MM, da Silva MA. Effects of orofacial myofunctional therapy on temporomandibular disorders. Cranio. 2010;28(4):249-59.

Ferreira TS, Mangilli LD, Sassi FC, et al. Speech and myofunctional exercise physiology: a critical review of literature. J Soc Bras Fonoaudiol. 2011;23(3):288-96.

Forrest K. Are oral-motor exercises useful in the treatment of phonological/articulatory disorders. Semin Speech Lang. 2002;23(1):15-26.

Foundas AL, Mock JR, Corey DM et al. The SpeechEasy device in stuttering and nonstuttering adults: fluency effects while speaking and reading. Brain Lang. 2013 ;126(2):141-50.

Gallop RF, Runyan CM. Long-term effectiveness of the SpeechEasy fluency-enhancement device. J Fluency Disord. 2012;37(4):334-343.

General Assembly of Pennsylvania. House bill no. 1150. [State of Pennsylvania Web site]. 07/01/2008. Available at:http://www.legis.state.pa.us/cfdocs/legis/PN/Public/btCheck.cfm?txtType=HTM&sessYr=2007&sessInd=0&billBody=H&billTyp=B&billNbr=1150&pn=4133. Accessed July 09, 2018.

Hauner KKY, Shriberg LD, Kwiatkowski J, Allen CT. A subtype of speech delay associated with developmental psychosocial involvement. J Speech, Lang, Hear Res. 2005;48(3):635-650.

Kiger M, Brown CS, Watkins L. Dysphagia management: an analysis of patient outcomes using VitalStim therapy compared to traditional swallow therapy. Dysphagia. 2006;21(4):243-253.

Lin, Pei-Hung, et al. Effects of functional electrical stimulation on dysphagia caused by radiation therapy in patients with nasopharyngeal carcinoma. Support Care Cancer. 2011l;19(1):91-99.

Lincoln M, Packman A, Onslow M. Altered auditory feedback and the treatment of stuttering: A review. J Fluency Disorders. 2006;31:71-89.

Loo J, Bamiou D, Campbell N, Luxon L. Computer-based auditory training (CBAT): benefits for children with language- and reading-related learning difficulties. Dev Med Child Neurol.2010;52:708-717.

Mason RM. A retrospective and prospective view of orofacial myology. Int J Orofacial Myology. 2008;34:5-14.

Nam-Jong P. Dysphagia. [e-Medicine Web Site]. 02/23/2018. Available at: http://www.emedicine.com/pmr/topic194.htm. Accessed July 09, 2018.

National Institute on Deafness and Other Communication Disorders (NIDCD). Stuttering. [NIDCD Web site]. 03/06/2017. Available at: http://www.nidcd.nih.gov/health/voice/Pages/stutter.aspx. Accessed July 25, 2018.

New Jersey Annotated Statutes. Title 17 Corporations and institutions for finance and insurance. Subtitle 3: Insurance. Part 9: Hospital and medical service corporations, etc. Chapter 48E: Health service corporations. Coverage for audiology and speech-language pathology services. West Group. 2002. Current through L.2002, c.44. 17:48E-35.17.

New Jersey Permanent Statutes. Title 17B Insurance. 17B:26-2.1p Health insurance policy to cover certain audiology, speech-language pathology services. L.1997, c.419, s.4.

New Jersey Permanent Statutes. Title 17B Insurance. 17B:27-46.1s. Group health insurer to cover certain audiology, speech-language pathology services. L.1997, c.419, s.5.

Novitas Solutions, Inc. Local Coverage ArticleA54111. Speech language pathology (SLP) services: communication disorders. [Novitas Solutions, Inc. Web site]. 10/01/2015. Revised 03/29/2018. Available at:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54111&ver=15&Date=&DocID=A54111&bc=hAAAABAAAAAA&. Accessed July 25, 2018.

Novitas Solutions, Inc. Local Coverage Determination (LCD) L35070: Speech-language pathology (SLP) services: communication disorders. [Novitas Solutions, Inc. Web site]. 10/01/2015. Revised 03/29/2018. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35070&ver=61&Date=&DocID=L35070&bc=iAAAABAAAAAA&. Accessed July 25, 2018.

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=18&Date=&DocID=L34891&bc=iAAAABAAAAAA&. Accessed July 25, 2018.

Permsirivanich, Wutichai, et al. Comparing the effects of rehabilitation swallowing therapy vs. neuromuscular electrical stimulation therapy among stroke patients with persistent pharyngeal dysphagia: a randomized controlled study. Med J Med Assoc Thailand.2009;92(2):259.

Pollard R, Ellis JB, Finan D, Ramig PR. Effects of the SpeechEasy® on objective and perceived aspects of stuttering: a six-month, phase I clinical trial in naturalistic environments. J Speech Lang Hear Res.2009;52(2);516-533.

Powell TW. An integrated evaluation of nonspeech oral motor treatments. Lang Speech Hear Serv Sch. 2008;39(3):422-7.

Ray J. Functional outcomes of orofacial myofunctional therapy in children with cerebral palsy. Int J Orofacial Myology. 2001;27:5-17.

Ryu, Ju Seok, et al. The effect of electrical stimulation therapy on dysphagia following treatment for head and neck cancer. Oral Oncol.2009;45(8):665-668.

Shaw GY, Sechtem PR, Searl J, et al. Transcutaneous neuromuscular electrical stimulation (VitalStim) curative therapy for severe dysphagia: myth or reality? Ann Otol Rhinol Laryngol. 2007;116(1):36-44.

SpeechEasy®. SpeechEasy® is Stuttering Management. [SpeechEasy® Web site]. 2013. Available at: http://www.speecheasy.com/. Accessed April 18, 2017.

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 April 18, 2017.

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 April 18, 2017.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. VitalStim® Experia. 510(k) summary. [FDA Web site]. 06/11/2007. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf7/K070425.pdf. Accessed April 18, 2017.

US Food and Drug Administration (FDA). Centers for Devices and Radiological Health (CDRH). VitalStim® Plus Electrotherapy System. 510(k) summary. [FDA Web site]. 02/08/2016. Available at:https://www.accessdata.fda.gov/cdrh_docs/pdf15/k153224.pdf. Accessed April 18, 2017.

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 April 18, 2017.

VitalStim® Therapy. VitalStim® Plus. [DJO Global/VitalStim® Web site]. Available at:
http://www.djoglobal.com/vitalstim. Accessed April 18, 2017.

Xia, Wenguang, et al. Treatment of post-stroke dysphagia by vitalstim therapy coupled with conventional swallowing training. J Huazhong University Sci Technol [Medical Sciences]. 2011;31:73-76.





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)

92507, 92508, 92521, 92522, 92523, 92524, 92526, 92607, 92608, 92609, 92610, 97127


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)

N/A


HCPCS Level II Code Number(s)



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

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


Cross References

Attachment A : Speech Therapy
Description: NJ mandate for biologically-based mental illness (BBMI) regulations in regard to outpatient speech therapy




Policy History

10.06.01k
09/26/2018The 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 / Modifier code update, effective 01/01/2018.

The following CPT, Modifier codes have been termed from this policy:
97532, Modifier SZ

The following CPT, HCPCS, Modifier codes have been added to this policy
97127, G0515, Modifiers 96, 97


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2018
Version Issued Date: 12/29/2017
Version Reissued Date: 09/26/2018

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