Application of the General Principles to Speech-Language

40.2.3 - Application of the General Principles to Speech-Language Pathology Services (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14) The following discussion of skilled speech-language pathology services applies the principles to specific speech-language pathology services about which questions are most frequently raised. Coverage of speech-language pathology services is not determined solely on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care. Assuming all other eligibility and coverage requirements have been met, skilled speech-language pathology services are covered when the individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified speech-language pathologist are necessary. As described in §40.2.1(b), at defined points during a course of therapy, the qualified speech-language pathologist must perform the ordered therapy service visit, assess the patient’s function using a method which allows for objective measurement of function and comparison of successive measurements, and document the results of the assessments, corresponding measurements, and effectiveness of therapy in the patient’s clinical record. Refer to §40.2.1(b) for specific timing and documentation requirements associated with these requirements. 1. The skills of a speech-language pathologist are required for the assessment of a patient's rehabilitation needs (including the causal factors and the severity of the speech and language disorders), and rehabilitation potential. Reevaluation would be considered reasonable and necessary only if the patient exhibited: • A change in functional speech or motivation; • Clearing of confusion; or • The remission of some other medical condition that previously contraindicated speech-language pathology services. Where a patient is undergoing restorative speech-language pathology services, routine reevaluations are considered to be a part of the therapy and cannot be billed as a separate visit. 2. The services of a speech-language pathologist would be covered if they are needed as a result of an illness or injury and are directed towards specific speech/voice production. 3. Speech-language pathology would be covered where a skilled service can only be provided by a speech-language pathologist and where it is reasonably expected that the skilled service will improve, maintain, or prevent or slow further deterioration in the patient’s ability to carry out communication or feeding activities. 4. The services of a speech-language pathologist to establish a hierarchy of speech- voice-language communication tasks and cueing that directs a patient toward speech- language communication goals in the plan of care would be covered speech-language pathology. 5. The services of a speech-language pathologist to train the patient, family, or other caregivers to augment the speech-language communication, treatment, to establish an effective maintenance program, or carry out a safe and effective maintenance program when the particular patient’s special medical complications require the skills of a qualified therapist (not an assistant) to perform a therapy service that would otherwise be considered unskilled or the needed therapy procedures are of such complexity that the skills of a qualified therapist are required to perform the procedures, would be covered speech-language pathology services. 6. The services of a speech-language pathologist to assist patients with aphasia in rehabilitation of speech and language skills are covered when needed by a patient. 7. The services of a speech-language pathologist to assist patients with voice disorders to develop proper control of the vocal and respiratory systems for correct voice production are covered when needed by a patient.