Clinical UM Guideline

 

Subject: Speech-Language Pathology Services
Guideline #:  CG-REHAB-06 Publish Date:    04/25/2018
Status: Reviewed Last Review Date:    03/22/2018

Description

This document addresses speech-language pathology (SLP) services provided for the identification, assessment and treatment of speech, language and swallowing disorders in children and adults.

SLP rehabilitative services are intended to improve, adapt or restore functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality involving goals an individual can reach in a reasonable period of time. Benefits will end when treatment is no longer medically necessary and the individual stops progressing toward those goals.

SLP habilitative services are intended to maintain, develop or improve skills which have not (but normally would have) developed or which are at risk of being lost as a result of illness, injury, loss of a body part, or congenital abnormality. Examples include therapy for a child who is not speaking at the expected age.

Speech therapy covers a wide range of services for all ages, from birth to very old age, and is provided in schools, hospitals, home care, rehabilitation centers, and nursing homes. Speech-language pathologists (SLPs) work with individuals who have physical or cognitive deficits/disorders resulting in difficulty communicating. Communication includes speech (articulation, voice, linguistics) and language (phonology, morphology, syntax, semantics, pragmatics, both receptive and expressive language, including reading and writing). SLPs treat acquired reading and writing impairments in adults and children who have previously learned how to read and write and are diagnosed with neurologic impairments. SLP also provide services for individuals with dysphagia (difficulty swallowing).

Note: The availability of rehabilitative and/or habilitative benefits for these services, state and federal mandates, and regulatory requirements should be verified prior to application of criteria listed below. Benefit plans may include a maximum allowable speech therapy benefit, either in duration of treatment or in number of visits. When the maximum allowable benefit is exhausted, coverage will no longer be provided even if the medical necessity criteria described below are met.

Note: Please see the following related documents for additional information:

Clinical Indications

Rehabilitative Services

Medically Necessary:

Rehabilitative speech-language pathology (SLP) services are considered medically necessary when ALL of the following criteria are met:

  1. The services are used in the treatment of communication impairment or swallowing disorders resulting from illness*, injury, surgery, or congenital abnormality; and
  2. Based on a plan of care, the therapy sessions achieve a specific diagnosis-related goal for a individual who has a reasonable expectation of achieving measurable significant functional improvement in a reasonable and predictable period of time [that is, medical necessity continues until progress is no longer being made (each three to six month period) or the individual has attained the previous level of competency]; and
  3. The therapy sessions provide specific, effective, and reasonable treatment for the individual’s diagnosis and physical condition; and
  4. The services are delivered by a qualified provider of speech therapy services (see definition); and
  5. The services require the judgment, knowledge, and skills of a qualified provider of SLP services due to the complexity and sophistication of the therapy and the medical condition of the individual.

*Note: Illness includes a wide range of conditions. For purposes of clarity, illness includes, but is not limited to, autism spectrum disorder.

Not Medically Necessary:

Maintenance (see definitions) therapy is considered not medically necessary as a rehabilitative service.

Rehabilitative SLP services are considered not medically necessary if any of the following is determined:

  1. The therapy is not aimed at improving, correction of a speech, language, or swallowing impairment other than that resulting from illness, injury, surgery or congenital abnormality.
  2. The therapy is for dysfunctions that are self-correcting, such as:
    1. Language therapy for young children with natural dysfluency; or
    2. Developmental articulation errors that are self-correcting.
  3. The therapy is considered primarily educational.
  4. The expectation does not exist that the speech therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time.
  5. Services that do not require the skills of a qualified provider of SLP services including, but not limited to, the following:
    1. Treatments that maintain function using routine, repetitious, or reinforced procedures that are neither diagnostic nor therapeutic (for example, practicing word drills for developmental articulation errors);
    2. Procedures that may be carried out effectively by the individual, family, or caregivers.
  6. Routine reevaluations not meeting the above criteria.
  7. Treatments that are not supported in peer-reviewed literature.

Duplicate rehabilitative therapy is considered not medically necessary. When individuals receive physical, occupational, or speech therapy, the therapists should provide different treatments that reflect each therapy discipline’s unique perspective on the individual’s impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals.

Habilitative Services

Medically Necessary:

Habilitative SLP services are medically necessary when ALL of the following criteria are met:

  1. The therapy is intended to maintain or develop speech, language, or swallowing impairment skills which , as a result of illness*, injury, loss of a body part, or congenital abnormality, either:
    1. have not (but normally would have) developed; or
    2. are at risk of being lost; and
  2. The services are evidence-based and require the judgment, knowledge, and skills of a qualified provider of SLP services due to the complexity of the therapy and the medical condition of the individual; and
  3. There is the expectation that the therapy will assist development of normal function or maintain a normal level of function; and
  4. There is a written treatment plan documenting the short- and long-term goal(s) of treatment, frequency and duration of treatment (including an estimate of when the goals will be met), and what quantitative measures will be used to assess objectively the level of functioning; and
  5. An individual would either not be expected to develop the function or would be expected to permanently lose the function (not merely experience fluctuation in the function) without the habilitative service; if the undeveloped or impaired function is not the result of a loss of body part or injury, a physician experienced in the evaluation and management of the undeveloped or impaired function has confirmed that the function would either not be expected to develop or would be permanently lost without the habilitative service and concurs that the written treatment plan is likely to result in meaningful development of the function or prevention of loss of the function; and
  6. The therapy documentation objectively verifies that, at a minimum, functional status is developed or maintained; and
  7. The services are delivered by a qualified provider of speech therapy services (see definition).

*Note: Illness includes a wide range of conditions. For purposes of clarity, illness includes but is not limited to autism spectrum disorder or developmental delay.

Not Medically Necessary:

Habilitative SLP services are not medically necessary if any of the following is determined:

  1. The therapy is not aimed at developing or maintaining functions, which would normally develop.
  2. The therapy is aimed at a function which would be permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality whether or not therapy was provided.
  3. The therapy is considered primarily educational.
  4. The expectation does not exist that the speech therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time.
  5. Services that do not require the skills of a qualified provider of speech therapy services including, but not limited to, the following:
    1. Treatments that maintain function using routine, repetitious, or reinforced procedures that are neither diagnostic nor therapeutic (for example, practicing word drills for developmental articulation errors);
    2. Procedures that may be carried out effectively by the individual, family, or caregivers.
  6. Routine reevaluations -not meeting the above criteria.
  7. Treatments that are not supported in peer-reviewed literature.

Duplicate habilitative therapy is considered not medically necessary. When individuals receive physical, occupational, or speech therapy, the therapists should provide different treatments that reflect each therapy discipline’s unique perspective on the individual’s impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals.

Documentation

Evaluation
A comprehensive evaluation is essential to determine if SLP services are medically necessary, gather baseline data, establish a treatment plan, and develop goals based on the data. The initial evaluation is usually completed in one to three sessions. An evaluation is needed before implementing any SLP treatment. Evaluation begins with the administration of appropriate and relevant assessments using standardized assessments and tools. The evaluation must include:

Treatment Sessions
A speech language pathology treatment session is usually defined as thirty minutes to one hour of speech therapy on any given day, depending on the age and diagnosis and ability to sustain attention for therapy. Treatment sessions for more than one hour per day may be medically appropriate for inpatient acute settings, day treatment programs, and select outpatient situations, but must be supported in the treatment plan and based on an individual’s medical condition. These services may include:

Documentation of treatment sessions must include:

Progress Reports
In order to reflect that continued SLP services are medically necessary, intermittent progress reports must demonstrate that the individual is making functional progress. Progress reports should meet the American Speech-Language-Hearing Association (ASHA) standards, which include at a minimum:

Re-evaluation
A re-evaluation is usually indicated when there are new significant clinical findings, a rapid change in the individual’s status, or failure to respond to SLP interventions. There are several routine re-assessments that are not considered re-evaluations. These include ongoing re-assessments that are part of each skilled treatment session, progress reports, and discharge summaries. 

Re-evaluation is a more comprehensive assessment that includes all the components of the initial evaluation, such as:

Providers of SLP Services

The services are delivered by a qualified provider who holds the appropriate credentials in speech-language pathology; has pertinent training and experience; and is certified, licensed, or otherwise regulated by the State or Federal governments. Assistants may provide services under the direction and supervision of a speech language pathologist. These qualified professionals are also regulated by the State and Federal governments.

Aides, athletic trainers, exercise physiologists, life skills trainers, and rehabilitation technicians do not meet the definition of a qualified practitioner regardless of the level of supervision. Aides and other nonqualified personnel as listed above are limited to non-skilled services such as preparing the individual, treatment area, equipment, or supplies; assisting a qualified therapist or assistant; and transporting individuals. They may not provide any direct treatments, modalities, or procedures.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

92507

Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual

92508

Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals

92521

Evaluation of speech fluency (eg, stuttering, cluttering)

92522

Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)

92523

Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)

92524

Behavioral and qualitative analysis of voice and resonance

92526

Treatment of swallowing dysfunction and/or oral function for feeding

92610

Evaluation of oral and pharyngeal swallowing function

92611

Motion fluoroscopic evaluation of swallowing function by cine or video recording

92626-92627

Evaluation of auditory rehabilitation status [includes codes 92626, 92627]

92630

Auditory rehabilitation; prelingual hearing loss

92633

Auditory rehabilitation; postlingual hearing loss

 

 

HCPCS

 

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 effective therapy maintenance program, each 15 minutes

S9128

Speech therapy, in the home, per diem

S9152

Speech therapy, re-evaluation

V5362

Speech screening

V5363

Language screening

V5364

Dysphagia screening

 

 

 

Note: the following CPT informational modifiers may be used with the above procedure codes:

96

Habilitative Services

97

Rehabilitative Services

Definitions

Developmental delay: A condition that occurs when a child is not developing or achieving skills by the expected time frame. Developmental delay can occur in one or many areas -for example, thinking (cognitive), gross or fine motor, language or social skills (American Academy of Pediatrics, 2006).

Maintenance treatments: Services intended to preserve the individual’s present level range, strength, coordination, balance, pain, activity, function, etc. and prevent regression of the same parameters. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur.

Qualified provider of speech language pathology services: One who is licensed where required and performs within the scope of licensure to furnish therapy services.

Discussion/General Information

According to the National Institute of Deafness and Other Communicative Disorders (NIDCD), in 2015 approximately 42 million people (1 in 6) in the United States have some type of communication disorder. Of these, 28 million have communication disorders associated with hearing loss, and 14 million have disorders of speech, voice, or language not associated with hearing loss (NIDCD, 2015).

References

Peer Reviewed Publications:

  1. Baille MF, Arnaud C, Cans C, et al. Prevalence, aetiology, and care of severe and profound hearing loss. Arch Dis Child. 1996; 75(2):129-132.
  2. Enderby P, Emerson J. Speech and language therapy: does it work? BMJ. 1996; 312(7047):1655-1658.
  3. Glade MJ. Diagnostic and therapeutic technology assessment: speech therapy in patients with a prior history of recurrent or chronic otitis media with effusion. Amer Med Assoc. Jan 5, 1996.
  4. Herd CP, Tomlinson CL, Deane KH, et al. Speech and language therapy versus placebo or no intervention for speech problems in Parkinson's disease. Cochrane Database Syst Rev. 2012;(8):CD002812.
  5. Lancer JM, Syder D, Jones AS, La Boutillier A. The outcome of different management patterns for vocal cord nodules. J Laryngol Otol. 1988; 102(5):423-427.
  6. Lewis BA, Freebairn L. Residual effects of preschool phonology disorders in grade school, adolescence, and adulthood. J Speech Hear Res. 1992; 35(4):819-831.
  7. Niskar AS, Kieszak SM, Holmes A, et al. Prevalence of hearing loss among children 6 to 19 years of age: the third National Health and Nutrition Examination Survey. JAMA. 1998; 279(14):1071-1075.
  8. Pennington L, Goldbart J, Marshall J. Speech and language therapy to improve the communication skills of children with cerebral palsy. Cochrane Database Syst Rev. 2003;(3):CD003466.
  9. Scarborough HS, Dobrich W. Development of children with early language delay. J Speech Hear Res. 1990; 33(1):70-83.
  10. Shriberg LD, Aram DM, Kwiatlowski J. Developmental apraxia of speech: I. Descriptive and theoretical perspectives. J Speech Lang Hear Res. 1997; 40(2):273-285.
  11. Sneed RC, May WL, Stencel C. Physicians’ reliance on specialists, therapists, and vendors when prescribing therapies and durable medical equipment for children with special health care needs. Am Acad Pediatr. 2001; 107(6):1283-1290.
  12. Sommers RK, Logsdon BS, Wright JM. A review and critical analysis of treatment research related to articulation and phonological disorders. J Commun Disord. 1992; 25(1):3-22.
  13. Wambaugh JL, Kalinyak-Fliszar MM, West JE, Doyle PJ. Effects of treatment for sound errors in apraxia of speech and aphasia. J Speech Lang Hear Res. 1998; 41(4):725-743.
  14. Van Demark DR, Hardin MA. Effectiveness of intensive articulation therapy for children with cleft palate.  Cleft Palate J. 1986; 23(3):215-224.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. Coverage Issues Manual. Pub 6. Available at: http://www.cms.hhs.gov/Manuals/PBM/list.asp. Accessed February 12, 2018.
  2. Centers for Medicare and Medicaid Services (CMS). Pub. 100-02, Chapter 15, Sections 220. Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance and Section 230. Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology. September 3, 2014. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed on February 12, 2018.
  3. Centers for Medicare and Medicaid Services. Manual. Available at: http://www.cms.hhs.gov/Manuals/PBM/list.asp. Accessed on February 12, 2018.
    • Home Health Agency Manual. Pub 11. Effective May 11, 2015.
    • Hospital Manual. Pub 10. Effective September 8, 2005.
  4. Centers for Medicare and Medicaid Services. National Coverage Determination. Available at: http://www.cms.gov/mcd/index_list.asp?list_type=ncd. Accessed on February 12, 2018.
    • Institutional and Home Care Patient Education Programs. NCD#170.1. Effective date not posted.
    • Speech-Language Pathology Services for the Treatment of Dysphagia. NCD #170.3. Effective October 1, 2006.
  5. Miller EL, Murray L, Richards L, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke. 2010; 41(10):2402-2448.
Websites for Additional Information
  1. American Speech-Language-Hearing Association. Aphasia. Available at: http://www.asha.org/public/speech/disorders/Aphasia. Accessed on February 12, 2018.
  2. American Speech-Language-Hearing Association. Feeding and swallowing disorders (dysphagia) in children. Available at: http://www.asha.org/public/speech/swallowing/FeedSwallowChildren.htm. Accessed on February 12, 2018.
  3. American Speech-Language-Hearing Association. Orofacial myofunctional disorders (OMD). Available at: http://www.asha.org/public/speech/disorders/Orofacial-Myofunctional-Disorders/. Accessed on February 12, 2018.
  4. American Speech-Language-Hearing Association. Speech and language disorders and diseases. Available at: http://www.asha.org/public/speech/disorders/. Accessed on February 12, 2018.
  5. American Speech-Language-Hearing Association. Swallowing disorders (dysphagia) in adults. Available at: http://www.asha.org/public/speech/swallowing/SwallowingAdults.htm. Accessed on February 12, 2018.
  6. American Speech-Language-Hearing Association. Typical speech and language development. Available at: http://www.asha.org/public/speech/development/. Accessed on February 12, 2018.
  7. National Dissemination Center for Children with Disabilities. Speech and language impairments. Last updated June 16, 2010. Available at: http://www.parentcenterhub.org/repository/speechlanguage/. Accessed on February 12, 2018.
  8. National Institute on Deafness and other Communicative Disorders. Aphasia. Updated March 6, 2017. Available at: http://www.nidcd.nih.gov/health/voice/pages/aphasia.aspx. Accessed on February 12, 2018.
  9. National Institute on Deafness and other Communicative Disorders. Apraxia of Speech. Updated October 31, 2017. Available at: http://www.nidcd.nih.gov/health/voice/pages/apraxia.aspx. Accessed on February 12, 2018.
  10. National Institute of Deafness and other Communicative Disorders. Statistics and Epidemiology. Updated June 2016. Available at: https://www.nidcd.nih.gov/health/statistics. Accessed on February 12, 2018.
  11. National Institute of Neurological Disorders and Stroke. Aphasia information page. Updated July 10, 2017. Available at: https://www.ninds.nih.gov/Disorders/All-Disorders/Aphasia-Information-Page. Access on February 12, 2018.
Index

Language Therapy (Speech Therapy)
Speech Language Pathology (SLP)
Speech Pathology      
Speech Therapy
ST (Speech Therapy)

History

Status

Date

Action

Reviewed

03/22/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section.

Reviewed

01/25/2018

MPTAC review. Updated References and Websites sections.

 

12/27/2017

The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2018 CPT and HCPCS changes; added modifiers 96 and 97, removed modifier SZ deleted 12/31/2017.

Revised

02/02/2017

MPTAC review. Reformatted clinical indications section. Clarified MN and NMN criteria for habilitative SLP services. Updated Definitions, References and Websites sections.

Revised

05/05/2016

MPTAC review. Defined abbreviation in rehabilitative MN criteria and habilitative NMN criteria. Updated Description, Discussion, References and Websites sections. Removed ICD-9 codes from Coding section.

Reviewed

05/07/2015

MPTAC review. Updated Description, References and Website sections.

Revised

11/13/2014

MPTAC review. Clarified note for rehabilitative and habilitative therapy. Updated References and Websites.

Revised

05/15/2014

MPTAC review. Clarified medically necessary criteria addressing rehabilitative SLP therapy. Revised medically necessary criteria to address habilitative SLP therapy. Clarified not medically necessary criteria addressing rehabilitative SLP therapy, duplicate rehabilitative therapy and maintenance therapy. Revised not medically necessary criteria to address habilitative SLP therapy. Updated Description, Definitions, References and Websites. Updated coding section with HCPCS modifier ‘-SZ’ effective 07/01/2014.

Reviewed

02/13/2014

MPTAC review. Websites updated.

 

01/01/2014

Updated Coding section with 01/01/2014 CPT changes; removed 92506 deleted 12/31/2013.

Reviewed

02/14/2013

MPTAC review. References and Websites updated.

Reviewed

02/16/2012

MPTAC review. References and Websites updated.

Reviewed

02/17/2011

MPTAC review. Term “and/or” removed from clinical indication criteria section. References and websites updated.

 

01/01/2011

Updated Coding section with 01/01/2011 HCPCS changes.

Reviewed

02/25/2010

Medical Policy & Technology Assessment Committee (MPTAC) review. Duration section removed. References updated.

 

01/01/2010

Updated coding section with 01/01/2010 HCPCS changes.

Reviewed

02/26/2009

MPTAC review. Removed Place of Service Section. References updated.

Reviewed

02/21/2008

MPTAC review. Coding section and References updated.

 

07/01/2007

Updated coding section with 07/01/2007 HCPCS changes.

Reviewed

03/08/2007

MPTAC review. References and coding updated. Title corrected.

Revised

03/23/2006

MPTAC review. Clarified “not medically necessary” language regarding developmental delays.

 

01/01/2006

Updated coding section with 01/01/2006 CPT/HCPCS changes

 

11/22/2005

Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).

Revised

09/22/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem BCBS

04/08/2005

RA-009 (Midwest Medical Review & UM criteria)

Speech Therapy For NASCO, FEP and ASA

Anthem BCBS

10/06/2002

Memo 1101 (S.E. Region)

Speech Therapy

WellPoint Health Networks, Inc.

03/01/2004

10.01.10

Speech Therapy