Speech-Language Pathology Services Policy from UniCare

by  Find-A-Code
October 27th, 2017

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:

• 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 or habilitation prognosis;
• Discharge plan that is initiated at the start of SLP treatment.

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:

• Evaluation;
• 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, for example, 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.

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:

• 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.

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:

• 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;
• Deciphering effectiveness of intervention(s).

Note: HCPCS modifier '-SZ' may be used with the above procedure codes to indicate 'habilitative services'

ICD-10 Diagnosis: All diagnoses

References:

• UniCare Clinical Indications for Speech-Language Pathology Services