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Date Printed: June 23, 2017: 11:44 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-92506-01

Original Effective Date: 09/15/02

Reviewed: 09/22/11

Revised: 12/01/16

Subject: Speech Therapy Services

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Speech therapy is the treatment of communication impairment and swallowing disorders. Speech therapy services aid in the development and maintenance of human communication and swallowing through assessment, diagnosis, and treatment.

Speech therapy should be provided in accordance with an ongoing, written plan of care. The purpose of the written plan of care is to assist in determining medical necessity.

Speech therapy services are considered medically necessary only if there is a reasonable expectation that speech therapy will achieve measurable improvement in the member's condition in a reasonable and predictable period of time.

The member should be re-evaluated regularly, and there should be documentation of progress made toward the designated goals. The treatment goals and subsequent documentation of treatment results should specifically demonstrate that speech therapy services are contributing to such improvement.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request to expedite the medical review process.

1. Click the link Speech Therapy Services - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

NOTE: Refer to member’s/subscriber’s contract benefits. Member’s/subscriber’s contract benefits may have limitations, exclusions, or criteria applicable to speech therapy services (see PROGRAM EXCEPTIONS).

Speech therapy services for swallowing disorders and speech-language disorders meet the definition of medical necessity when the following conditions are met:

Prior to the initiation of speech therapy, a comprehensive evaluation of the member’s speech and language potential is required. The initial speech and language evaluation should be performed by a qualified provider of speech therapy services, and should include:

• Specific statements regarding history and diagnosis;

• Standardized, age-appropriate testing results;

• Specific short-term and long-term goals with measurable objectives;

• The specific techniques and/or exercises to be used in the treatment; and

• The frequency and duration of the treatment.

Speech therapy services meet the definition of medical necessity when performed to improve or restore speech in members who have a swallowing or speech-language disorder that is associated with:

• An illness or condition (e.g., dysphagia, GERD)

• An exacerbation of a chronic illness or condition

• An injury or trauma

• A surgical procedure

• A congenital defect (e.g., cleft palate, cleft lip, etc.)

• Cerebrovascular accident (stroke)

Speech therapy is typically offered in school settings and in developmental learning centers. Speech therapy services do not meet the definition of medical necessity for conditions such as, but not limited to, the following:

Anti-stuttering devices (e.g., SpeechEasy) do not meet the definition of medical necessity.

In cases where the member receives both occupational and speech therapy, treatments should not be duplicated and separate treatment plans and goals should be provided.

Services for maintenance programs are not eligible for coverage. Maintenance consists of drills, techniques, and exercises that preserve the present level of function so as to prevent regression of the function and begins when therapeutic goals of treatment have been achieved and no further functional progress is apparent or expected.

BILLING/CODING INFORMATION:

The following codes may be used to describe speech therapy services:

HCPCS Coding:

G0153

Services performed by a qualified speech-language pathologist in the home

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 pathology maintenance program, each 15 minutes

S9128

Speech therapy, in the home, per diem

S9152

Speech therapy, re-evaluation

CPT Coding:

70370

Radiologic examination; pharynx or larynx, including fluoroscopy AND/OR magnification technique

70371

Complex dynamic pharyngeal and speech evaluation by cine or video recording

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 (includes aural rehabilitation); group, two 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

92607

Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour

92608

Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (list separately in addition to code for primary procedure)

92609

Therapeutic services for the use of speech-generating device, including programming and modification

96105

Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour

ICD-10 Diagnosis Codes That Support Medical Necessity: (Effective 10/01/15)

G20

Parkinson’s disease

G21.11 – G21.9

Secondary parkinsonism

G35

Multiple sclerosis

K21.0 – K21.9

Gastro-esophageal reflux disease with or without esophagitis

Q90.0

Trisomy 21, nonmosaicism (meiotic nondisjunction)

Q90.1

Trisomy 21, mosaicism (mitotic nondisjunction)

Q90.2

Trisomy 21, translocation

Q90.9

Down syndrome, unspecified

R13.0 – R13.19

Aphasia and dysphasia

R47.01

Aphasia

R49.1

Aphonia

REIMBURSEMENT INFORMATION:

NOTE: Refer to member’s/subscriber’s contract benefits. Member’s/subscriber’s contract benefits may have limitations, exclusions, or criteria applicable to speech therapy services (see PROGRAM EXCEPTIONS).

Reimbursement for evaluation for a prescription for speech generating augmentative and alternative communication devices (92607, 92608) is limited to one evaluation in a 12-month period.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Speech-Language Pathology Services for the Treatment of Dysphagia (170.3) located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Therapy and Rehabilitation Services (L29289) located at fcso.com.

Coverage mandated by the state of Florida: refer to member’s/subscriber’s contract benefits.

Coverage for speech therapy, occupational therapy, physical therapy, and applied behavior analysis is mandated by Florida statute for some contracts.

Florida Statute 627.6686 [Coverage for individuals with autism spectrum disorder required; exception] and Florida Statute 641.31098 [Coverage for individuals with developmental disabilities]:

A health maintenance contract shall provide coverage to an eligible individual for treatment of autism spectrum disorder and Down syndrome through speech therapy, occupational therapy, physical therapy, and applied behavior analysis.

When the mandate applies:

Children must be under 18 years of age, or still in high school, and have been diagnosed as having autism spectrum disorder at 8 years of age or younger, OR

Children must be under 18 years of age, or still in high school, and have been diagnosed as having Down syndrome.

DEFINITIONS:

Aphasia: loss of the power of expression by speech, writing, or signs, or of comprehending spoken or written language, due to injury or disease of the brain centers.

Aphonia: loss of voice.

Aphonia paralytica: loss of voice due to paralysis of disease of the laryngeal nerves.

Attention disorders: presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems.

Behavior disorders: exhibits disruptive actions such as physical aggression, excessive argumentativeness, oppositional defiant disorder (ODD), conduct disorder (CD), intermittent explosive disorder (age-inappropriate tantrums), and attention deficit hyperactivity disorder (ADHD).

Condition: a disease, illness, ailment, injury, or pregnancy.

Developmental delay: fails to achieve age-appropriate movement, language, cognitive, social and emotional milestones at the expected age targets.

Dysarthria: imperfect articulation of speech due to disturbances of muscular control which results from damage to the central or peripheral nervous system.

Dysarthria literalis: stuttering; also known as dysarthria syllabaris spasmodica.

Dysphagia: difficulty in swallowing.

Habilitative services: health care services that are short-term and help a person to acquire or attain an age-appropriate bodily function necessary to participate in activities of daily living.

Hysteric aphonia: loss of voice due to hysteria.

Learning disabilities: an inability to master certain skills due to the way the brain gets, uses, stores, and sends out information. Children with learning disabilities may have trouble with one or more of the following skills: reading, writing, listening, speaking, reasoning, and math.

Psychosocial speech delay: speech delay related to physical deprivation (e.g., poverty, poor housing, malnutrition) and social deprivation (e.g., inadequate linguistic stimulation, parental absenteeism, emotional stress, child neglect)

Rehabilitative services: health care services rendered for the purpose of restoring function lost due to illness, injury or surgical procedures.

Spastic aphonia: interference with the voice caused by muscular spasm.

RELATED GUIDELINES:

OTHER:

None applicable.

REFERENCES:

  1. American Academy of Family Physicians. Leung AKC, Kao CP. Evaluation and Management of the Child with Speech Delay. 1999.
  2. American Medical Association CPT (current edition).
  3. American Speech-Language-Hearing Association (ASHA). “Preferred Practice Patterns for the Profession of Speech-Language Pathology”; approved by the ASHA Legislative Council, November 2004.
  4. Blue Cross Blue Shield Association Medical Policy. Speech Therapy 8.03.04, (12/17/03).
  5. Buz Harlor AD Jr, Bower C. American Academy of Pediatrics Clinical Report. Hearing Assessment in Infants and Children: Recommendations Beyond Neonatal Screening. Pediatrics Vol. 124 No. 4 October 2009.
  6. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination Manual, Publication 100-3, Section 170.3. Speech Pathology Services for the Treatment of Dysphagia (Rev. 1, 10/01/06).
  7. First Coast Service Options (FCSO), Local Coverage Determination; Therapy and Rehabilitation Services (L29289), (01/01/11). Accessed 08/24/11.
  8. Florida Statute 641.31098, Coverage for individuals with developmental disabilities. Accessed at http://www.flsenate.gov/.
  9. Florida Statute 627.6686, Coverage for individuals with autism spectrum disorder required; exception. Accessed at http://www.flsenate.gov/.
  10. Lieu JEC. Hearing Loss in One Ear Leads to Speech-Language Delays. Healthy Children.org, via American Academy of Pediatrics. May 2010.
  11. Michaud LJ and the Committee on Children with Disabilities. American Academy of Pediatrics Clinical Report. Prescribing Therapy Services for Children with Motor Disabilities. Pediatrics Vol. 113 No. 6 June 2004.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/22/11.

GUIDELINE UPDATE INFORMATION:

09/15/02

Medical Coverage Guideline Reformatted.

05/15/04

Scheduled annual review; no change in coverage statement.

01/01/05

HCPCS coding update: revised descriptor for 96111.

01/01/06

Annual HCPCS coding update (revised 92506 and 92507, remove 96115).

04/15/06

Scheduled review; no change in coverage statement; references updated; guideline is moved to “no longer scheduled for review” (NLR) category.

10/15/06

Revisions consisting of the addition of a non-coverage statement for stuttering devices; revise coverage criteria; add G0153 and S9128; remove ICD-9 diagnosis code 784.5.

11/15/06

Add limitation for evaluation for 92607 and 92608.

07/01/07

HCPCS 3rd quarter coding update: added S9152.

09/15/07

Reviewed; reformatted guideline; updated ICDI-9 coding section; updated references.

04/01/09

Unscheduled review. Deleted ICD 9 code section. Add reference to member contract and program exception for Florida Statute 627.6686.

04/20/09

Replace previously deleted ICD 9 code section.

09/15/09

Updated exception section for treatment of autism.

10/15/10

Revision; related ICD-10 codes added.

01/01/11

Annual HCPCS coding update. Added code G0161; revised descriptor for code G0153.

08/15/11

Revision; ICD9 code range 787.20 added.

10/15/11

Unscheduled review. Revised MCG title, description section, position statement, ICD9 coding, ICD10 coding and definitions section. Updated references and reformatted guideline.

01/01/12

Annual HCPCS coding update. Revised G0161 descriptor.

01/01/14

Revision; updated position statement and definitions section. Annual CPT update: deleted 92506; added 92521, 92522, 92523, 92524. Program Exceptions section updated. Reformatted guideline.

10/01/15

Revision; updated ICD-9 and ICD-10 coding sections.

11/01/15

Revision: ICD-9 Codes deleted.

07/15/16

Revision: Updated Program Exceptions section and references.

09/15/16

Revision: updated Position Statement section and Definitions section.

12/01/16

Program Exceptions section revised.

Date Printed: June 23, 2017: 11:44 AM