Speech-language pathology (SLP) services provide for the identification, assessment and treatment of speech, language and swallowing disorders in children and adults. Therapy facilitates the development or rehabilitation of functional communication or swallowing.
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, prosody) 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: Many benefit plans 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:
Speech-language pathology (SLP) services are considered medically necessary when ALL of the following criteria are met:
- The services are used in the treatment of communication impairment or swallowing disorders resulting from illness, injury, surgery, or congenital abnormality; AND
- 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 [i.e., 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
- The therapy sessions provide specific, effective, and reasonable treatment for the individual's diagnosis and physical condition; AND
- The services are delivered by a qualified provider of speech therapy services. A qualified provider is one who is licensed, where required, or holds the Certificate of Clinical Competence (CCC) granted by the American Speech-Language-Hearing Association (ASHA), and performs within the scope of licensure; AND
- The services require the judgment, knowledge, and skills of a qualified provider of speech therapy services due to the complexity and sophistication of the therapy and the medical condition of the individual.
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:
- Prior functional level, if acquired condition;
- Specific standardized and non-standardized tests, assessments, and tools to assess the individual's level of functional communication/swallowing in that individual's natural environment(s);
- Analytic interpretation and synthesis of all data, including a summary of the baseline findings in written report(s) of the individual's current communication/swallowing skills;
- Objective, measurable, and functional descriptions of an individual's deficits using comparable and consistent methods;
- Summary of clinical reasoning and consideration of contextual factors with recommendations;
- Plan of care with specific treatment techniques or activities to be used in treatment sessions that should be updated as the individual's condition changes;
- Frequency and duration of treatment plan;
- Functional, measurable, and time-framed long-term and short-term goals based on appropriate and relevant evaluation data;
- Rehabilitation prognosis;
- Discharge plan that is initiated at the start of SLP treatment.
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:
- Therapeutic oral motor, laryngeal, pharyngeal, or breathing exercises;
- Compensatory or adaptive communication/swallowing techniques and skills;
- Management of positioning, eating, and swallowing to enable/progress safe eating and swallowing;
- Establishing hierarchy of tasks or cues that direct an individual toward goals;
- Skilled reassessment of the individual's problems, plan, and goals as part of the treatment session;
- Training of the individual, caregiver, and family/parent to augment restorative treatment or establish a maintenance program;
- Training in assistive technology and adaptive devices, e.g., speech generating devices;
- Training in the use of prosthetic devices;
- Coordination, communication, and documentation;
- Reevaluations, if there is a significant change in the individual's condition.
Documentation of treatment sessions must include:
- Date of treatment;
- Specific treatment(s) provided that match the CPT codes billed;
- Total treatment time;
- The individual's response to treatment;
- Skilled ongoing reassessment of the individual's progress toward the goals;
- Any progress toward the goals in objective, measurable terms using consistent and comparable methods;
- Any problems or changes to the plan of care;
- Name and credentials of the treating clinician.
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:
- Start of care date;
- Time period covered by the report;
- Communication/swallowing diagnosis;
- Statement of the individual's functional communication/swallowing at the beginning of the progress report period;
- Statement of the individual's current status as compared to evaluation baseline data and the prior progress reports, including objective measures of member communication/swallowing performance in functional terms that relate to the treatment goals;
- Changes in prognosis and why;
- Changes in plan of care and why;
- Changes in goals and why;
- Consultations with other professionals or coordination of services, if applicable;
- Signature and title of qualified professional responsible for the therapy services.
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:
- Data collection with objective measurements based on appropriate and relevant assessment tests and tools using comparable and consistent methods of the individual's level of functional communication/swallowing in that individual's natural environment(s);
- Making a judgment as to whether skilled care is still warranted;
- Organizing the composite of current problem areas and deciding a priority/focus of treatment;
- Identifying the appropriate intervention(s) for new or ongoing goal achievement;
- Modification of intervention(s);
- Revision in plan of care if needed;
- Correlation to meaningful change in function; and
- Deciphering effectiveness of intervention(s).
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.
Not Medically Necessary:
Speech-language pathology (SLP) services are considered not medically necessary if any of the following is determined:
- The therapy is for the correction of a speech, language, or swallowing impairment other than that resulting from illness, injury, surgery or congenital abnormality.
- The therapy is for dysfunctions that are self-correcting, such as:
- Language therapy for young children with natural dysfluency; or
- Developmental articulation errors that are self-correcting.
- The therapy is considered primarily educational.
- 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. [i.e., progress is no longer being made (in a three to six month period) or the individual has attained the previous level of competency].
- Services that do not require the skills of a qualified provider of ST services including, but not limited to, the following:
- Treatments that maintain function using routine, repetitious, or reinforced procedures that are neither diagnostic nor therapeutic (e.g., practicing word drills for developmental articulation errors);
- Procedures that may be carried out effectively by the individual, family, or caregivers.
- Routine reevaluations -not meeting the above criteria.
- Treatments that not supported in peer-reviewed literature.
Duplicate 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.
Maintenance programs are considered not medically necessary. A maintenance therapy program consists of drills, techniques, and exercises that preserve the individual's present level of communication/swallowing function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved and when no further consistent functional progress is apparent or expected to occur. In certain circumstances, the specialized knowledge and judgment of a qualified therapist maybe required to establish a maintenance program, however, the repetitive SLP services to maintain a level would be considered not medically necessary.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference. 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.
|92506||Evaluation of speech, language, voice, communication, and/or auditory processing|
|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|
|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|
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|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|
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|ICD-9 Diagnosis|| |
| ||All diagnoses|
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|ICD-10 Diagnosis||ICD-10-CM draft codes; effective 10/01/2014:|
| ||All diagnoses|
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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.
Peer Reviewed Publications:
- Baille MF, Arnaud C, Cans C, et al. Prevalence, etiology, and care of severe and profound hearing loss. Arch Dis Child. 1996; 75(2):129-132.
- Enderby P, Emerson J. Speech and language therapy: does it work? BMJ. 1996; 312(7047):1655-1658.
- 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.
- Lancer JM, Syder D, Jones AS, et al. The outcome of different management patterns for vocal cord nodules. J Laryngol Otol. 1988; 102(5):423-427.
- 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.
- 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.
- Scarborough HS, Dobrich W. Development of children with early language delay. J Speech Hear Res. 1990; 33(1):70-83.
- 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.
- 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.
- 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.
- 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.
- 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 Publication
- American Speech-Language-Hearing Association. Roles of speech-language pathologists in the identification, diagnosis, and treatment of individuals with cognitive-communication disorders: Position Statement (2005). Available at: http://www.asha.org/docs/html/PS2005-00110.html. Accessed on December 30, 2012.
- Centers for Medicare and Medicaid Services. Coverage Issues Manual. Pub 6. http://www.cms.hhs.gov/manuals/downloads/Pub06_TOC.pdf. Accessed December 30, 2012.
- 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. December 22, 2006. Available at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed on December 30, 2012.
- Centers for Medicare and Medicaid Services. Manual. Available at: http://www.cms.hhs.gov/Manuals/PBM/list.asp. Accessed on January 4, 2013.
- Home Health Agency Manual. Pub 11. Effective September 8, 2005.
- Hospital Manual. Pub 10. Effective September 8, 2005.
- Centers for Medicare and Medicaid Services. National Coverage Determination. Available at: http://www.cms.gov/mcd/index_list.asp?list_type=ncd. Accessed on December 30, 2012.
- 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.
- National Institute on Deafness and other Communicative Disorders. Information on Aphasia. Available at: http://www.nidcd.nih.gov/health/voice/pages/aphasia.aspx. Accessed on December 30, 2012.
- National Institute on Deafness and other Communicative Disorders. Information on Apraxia of Speech. Available at: http://www.nidcd.nih.gov/health/voice/pages/apraxia.aspx. Accessed on December 30, 2012.
- National Institute of Neurological Disorders and Stroke. Aphasia information page. Available at: http://www.ninds.nih.gov/disorders/aphasia/aphasia.htm. Access on December 30, 2012.
|Web Sites for Additional Information|
- American Speech-Language-Hearing Association. Aphasia. Available at: http://www.asha.org/public/speech/disorders/Aphasia. Accessed on December 30, 2012.
- 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 December 30, 2012.
- American Speech-Language-Hearing Association. Oral myofunctional disorders (OMD). Available at: http://www.asha.org/public/speech/disorders/OMD.htm. Accessed on December 30, 2012.
- American Speech-Language-Hearing Association. Speech and language disorders and diseases. Available at: http://www.asha.org/public/speech/disorders/. Accessed on December 30, 2012.
- American Speech-Language-Hearing Association. Swallowing disorders (dysphagia) in adults. Available at: http://www.asha.org/public/speech/swallowing/SwallowingAdults.htm. Accessed on December 30, 2012.
- American Speech-Language-Hearing Association. Typical speech and language development. Available at: http://www.asha.org/public/speech/development/. Accessed on December 30, 2012.
- National Dissemination Center for Children with Disabilities. Speech and language impairments. Available at: http://nichcy.org/disability/specific/speechlanguage. Accessed on December 30, 2012.
Language Therapy (Speech Therapy)
Speech Language Pathology (SLP)
ST (Speech Therapy)
|Reviewed||02/14/2013||Medical Policy & Technology Assessment Committee (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.|
|Updated Coding section with 01/01/2011 HCPCS changes. 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.|
Last Review Date
|RA-009 (Midwest Medical Review & UM criteria)||Speech Therapy For NASCO, FEP and ASA|
|Memo 1101 (S.E. Region)||Speech Therapy|
|WellPoint Health Networks, Inc.|