CAM 80304

Speech Therapy

Category:Therapy   Last Reviewed:June 2018
Department(s):Medical Affairs   Next Review:June 2019
Original Date:June 2013    

Description:
Speech therapy is the treatment of communication impairment and swallowing disorders. Speech therapy services facilitate the development and maintenance of human communication and swallowing through assessment, diagnosis and rehabilitation.

Policy:
Speech therapy services are considered medically necessary when used in the treatment of communication impairment or swallowing disorders due to disease, trauma, congenital anomalies or prior therapeutic intervention.

Speech therapy services are considered not medically necessary that are self-correcting, such as language therapy for young children with natural dysfluency or developmental articulation errors that are self-correcting.

Speech therapy sessions must meet ALL of the following criteria:

  • Treat the needs of a patient who suffers from communication impairment or swallowing disorder, due to disease, trauma, congenital anomalies or prior therapeutic intervention
  • Achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable time period
  • Provide specific, effective and reasonable treatment for the patient’s diagnosis and physical condition
  • Be delivered by a qualified, licensed provider of speech therapy services
  • Require the judgment, knowledge and skills of a qualified provider of speech therapy services due to the complexity and sophistication and the physical condition of the patient

A plan of care should include:

  • Specific statements of long- and short-term goals
  • Measurable objectives
  • A reasonable estimate of when the goals will be achieved
  • The specific treatment techniques and/or exercises to be used in the treatment
  • The frequency and duration of treatment

The plan of care should be updated and/or evaluated as the patient’s condition changes and should have recertification from the physician at least every 30 days.

Speech therapy is frequently used in school settings and in developmental learning centers. Speech therapy services are generally NOT COVERED for the following conditions:

  • Psychological speech delay
  • Behavioral problems
  • Attention disorders
  • Conceptual handicap
  • Mental retardation
  • Stammering, stuttering

PLEASE SEE SPECIFIC CONTRACT VERBIAGE FOR EXCLUSIONS, LIMITATIONS AND/OR MAXIMUMS RELATED TO PHYSICAL THERAPY, SPEECH THERAPY AND OCCUPATIONAL THERAPY.

NOTE: Homebound status is defined as an individual who normally would not be able to leave the home; however, due to illness or injury, leaving the home will now require considerable and taxing effort. An aged person who does not travel from their home because of feebleness and insecurity brought on by advanced age is NOT considered homebound.

PLEASE SEE CAM 191 MEDICAL RECORDS DOCUMENTATION STANDARDS

Rationale:
A search of literature was completed through the MEDLINE database for the period of January 1990 through October 1995. The search strategy focused on references containing the following medical subject heading:

  • Speech Therapy

See also:

  • Occupational Therapy, Medical Policy No. 80303

Documentation Requirements:
Provider Record-Keeping Requirements for Modalities and Therapeutic Procedures
Definitions

  • Modality/Modalities: Current Procedural Terminology (CPT) codes 97010 through 97039.
  • Therapeutic Procedure(s): CPT codes 97110 through 97564.
  • Timed Codes: Those modalities and therapeutic procedures that contain the phrase "each 15 minutes" in their code descriptors. For example, CPT code 97110 is a timed code. The descriptor for CPT code 97110 reads "Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility."

General Requirements:
Providers must maintain medical records that comport with the record-keeping standards of their profession. However, to the extent the provider’s profession’s record-keeping standards do not already require it, for a provider to be reimbursed for claims for modalities and/or therapeutic procedures, his or her medical records must also comply with the following requirements: 

  1. The date and the patient’s name must appear on each page of the patient’s medical records.
  2. Each patient encounter must be a separate record.
  3. The patient’s entire record must be legible (i.e., must be legible to someone other than the writer).
  4. Entries in the medical record must be made within a week of the provider performing the modalities and/or therapeutic procedures.
  5. The medical record must demonstrate that the modalities and/or therapeutic procedures are medically necessary.
  6. The medical records must demonstrate that the patient’s treatment plan is consistent with his or her diagnoses.
  7. CPT codes and ICD codes reported on claim forms or billing statements are supported by the documentation in the medical record.
  8. The provider must provide a definition sheet of abbreviations specific to his or her office to assist this health plan in interpreting patients’ medical records.
  9. Documentation corrections should be a single line drawn through the error, with the corrected text in close proximity, initialed and dated by the person who made the error.

Treatment Notes/Patient Encounter Notes
In addition, to the extent the provider’s profession’s record-keeping standards do not already require it, for a provider to be reimbursed for claims for modalities and/or therapeutic procedures, the following information must be recorded by the provider in each individual record of a patient encounter.

  1. A description, not a reiteration of the CPT code, of each individual modality and therapeutic procedure provided and billed in language that can be compared with the billing on the claim to verify correct coding
  2. For timed codes, an indication of the total number of minutes each individual modality and therapeutic procedure was performed
  3.  A description of the specific area of the patient’s body to which each individual modality and therapeutic procedure was directed and/or performed
  4. The legible signature and professional identification of the individual who furnished each individual modality or therapeutic procedure (This health plan does not recognize incident-to billing, but requires that claims be billed under the name of the provider who actually rendered the service, modality or therapeutic procedure.)
  5. The patient’s response to the treatment
  6. A skilled ongoing reassessment of the patient’s progress toward treatment goals
  7. A description of the patient’s progress toward the goals in objective, measurable terms using consistent and comparable methods
  8. A description of any patient problems or changes to the plan of care
  9. A description of the reason for the encounter
  10. A date for a return visit or follow-up plan

REMINDER:
This health plan does not recognize incident-to billing, but requires that claims be billed under the name of the provider who actually rendered the service, modality or therapeutic procedure.

Coding Section 

Codes Number Description
CPT  92507 Treatment of speech, language, voice, communication and/or auditory processing disorder; individual
  92508 group, two or more individuals
  92521 

Evaluation of speech fluency (e.g., stuttering, cluttering)

  92522  Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) 
  92523  Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language) 
  92524  Behavioral and qualitative analysis of voice and resonancE 
ICD-9 Procedure 93.72-93.75 Spreech therapy code range
ICD-9 Diagnosis 784.3 Aphasia
  784.41-784.49 Aphonia code range
  784.59

Other speech disturbance

  784.69 Other symptoms involving hard/neck (code for anomia)
  787.2 Dysphasia
    (Note: Policy states due to disease, trauma, congenital anomalies or prior therapeutic intervention – unable to code, nonspecific)
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 and effective therapy maintenance program, each 15 minutes
  S9128 Speech therapy in the home, per diem
  S9152 Speech therapy, re-evaluation
ICD-10-CM (effective 10/01/15) R47.01-R47.9 Speech disturbances not elsewhere classified
  R49.0-R49.9 Voice and resonance disorders code range
  R13.0-R13.19 Aphagia and dysphagia code range
  R48.1 Agnosia
  R49.1 Aphonia
  R48.8 Other voice and resonance disorders
  R48.9 Unspecified symbolic dysfunctions
ICD-10-PCS (effective 10/01/15)   ICD-10-PCS codes are only used for inpatient services. The following code ranges are available for speech therapy services provided inpatient.
  F00- Physical rehabilitation, speech assessment, code range
  F06- Physical rehabilitation, speech treatment, code range
  F0D- Physical rehabilitation, device fitting, code range
Type of Service Medical  
Place of Service Inpatient/Outpatient  
Modifiers     Effective 01/01/2018, the following modifiers should be used to denote if the services rendered are habilitative or rehabilitative: 
  96 (effective 1/1/2018) Habilitative Services 
  97 (effective 1/1/2018) Rehabilitative Services 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward       

05/30/2018 

Annual review, adding note directing reader to CAM 191 Medical Records Documentation Standards. No other changes made. 

11/27/2017 

Interim review, removing developmental delay from list of issues not generally covered for speech therapy. Also will be adding new modifiers for 2018. 

06/12/2017 

Annual review, no change to policy intent. 

05/12/2017

Corrected review date. No other changes made. 

02/06/2017 

Updated Coding. No change to policy intent.

06/01/2016 

Annual review, no change to policy intent. 

06/02/2015 

Annual review, no change to policy intent. Added coding.

06/05/2014

Annual review. No changes made to policy.


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