Compliance with the provisions in this policy may be monitored and addressed
through post payment data analysis and subsequent medical review audits.

**History/Background and/or General Information**

This LCD provides guidelines for selected speech-language pathology (SLP)
services for communication disorders.

The speech-language pathology services discussed in this LCD are those
evaluation and therapeutic services necessary for the diagnosis and treatment
of speech and language disorders, which result in communication disabilities;
and for the diagnosis and treatment of cognitive communication impairments.

Speech-language pathology services are designed to improve or restore speech
and language functioning (communication) following disease, injury or loss of
a body part. Clinicians use the clinical history, systems review, physical
examination, and a variety of evaluations to characterize individuals with
impairments, functional limitations and disabilities. Impairments, functional
limitations and disabilities thus identified are then addressed by the design
and implementation of therapeutic interventions tailored to the specific needs
of the individual patient.

**Covered Indications**

For information regarding skilled therapy services, please see CMS IOM
Publication 100-02, _Medicare Benefit Policy Manual_ , Chapter 8 and Chapter
15, Sections 220 and 230.

For information on conditions necessary for SLP services to be considered
reasonable and necessary, please refer to the applicable CMS IOM references.

***Restorative/Rehabilitative Therapy**

Please see IOM Publication 100-02, _Medicare Benefit Policy Manual_ , Chapters
8 and Chapter 15 Section 220.3.D, for information on rehabilitative therapy
and necessary documentation. Documentation must justify the necessity of the
services.

****Maintenance Therapy/Program (skilled)**

Please see CMS IOM Publication 100-02, _Medicare Benefit Policy Manual_ ,
Chapter 8, Chapter 12 and Chapter 15, Section 220.3.D, for information on
maintenance therapy and skilled therapy services and necessary documentation
for those services. Documentation must justify the necessity of the services.

**SLP EVALUATION AND DIAGNOSTIC SERVICES**

The evaluation of a patient's level of function is focused on identifying what
the patient wants and needs to do, and on identifying those factors that help
or hinder the performance of those activities. Please see CMS IOM Publication
100-02, _Medicare Benefit Policy Manual_ , Chapter 15 for information
regarding clinician evaluation, re-evaluation and documentation of SLP
evaluation and diagnostic services.

**Speech/hearing evaluation**

In addition to the general information in the above CMS manual, the evaluation
includes the identification, assessment, diagnosis, and evaluation for
disorders of speech, articulation, fluency, and voice (including respiration,
phonation, and resonance); language skills (involving the parameters of
phonology, morphology, syntax, semantics, and pragmatics, and including
disorders of receptive and expressive communication in oral, written, graphic,
and manual modalities); and cognitive aspects of communication (including
communication disability and other functional disabilities associated with
cognitive impairment).

Speech/hearing evaluation for disorders of the auditory system may also be
considered here, such as auditory processing evaluation. For more information
please see CMS IOM Publication 100-02, _Medicare Benefit Policy Manual_ ,
Chapter 15, Section 220, referenced in the CMS National Coverage Policy
section of this policy.

**Evaluation for use and/or fitting of voice prosthetic device to supplement
oral speech**

This includes selection of a standard or indwelling voice prosthesis,
determination of appropriate size prosthesis and fitting a tracheostomy valve
and includes instructions for care and cleaning.

**Evaluation of patient for prescription of speech-generating devices**

Evaluation of language comprehension and production across modalities:
written, spoken, and gestural and may also include evaluation of the ability
to operate and effectively use a speech generating device or aid. This
evaluation may also include evaluating motor skills and nonverbal
communication strategies (e.g. words, pictures, and vocalizations).

**Assessment of Aphasia**

The assessment of expressive and receptive speech and language function,
language comprehension, speech production ability, reading, spelling, and
writing, with interpretation and report (per hour). Examples of assessments
used include the Boston Diagnostic Aphasia Examination, the Western Aphasia
Battery, and the Minnesota Differential Diagnosis Examination of Aphasia.

A comprehensive aphasia assessment is generally covered once.

Please see CMS IOM 100-02, _Medicare Benefit Policy Manual_ , Chapter 15,
Section 230.3 for documentation requirements of therapy services.

**Developmental test administration; extended**

This includes assessment of fine and/or gross motor, language, cognitive
level, social, memory and/or executive functions by standardized developmental
instruments when performed; with interpretation and report.

**Standardized cognitive performance testing**

This includes testing such as the Ross Information Processing Assessment (per
hour) including both face-to-face time and non-face-to-face time interpreting
these test results and preparing the report. Standardized tests may be norm-
referenced (results are interpreted based on established norms and compare
test-takers to each other) or criterion-referenced (results are interpreted
based on the person's performance/ability to complete tasks or demonstrate
knowledge of a specific topic).

**SLP THERAPEUTIC SERVICES**

**Speech/hearing therapy**

The treatment/intervention, (e.g., prevention, restoration, amelioration, and
compensation) and follow-up services for disorders of speech, articulation,
fluency and voice, language skills and the cognitive aspect of communication.

  1. Providing consultation, counseling, and making referrals when appropriate.
  2. Providing training and support to family members/caregivers and other communication partners of individuals with speech, voice, language, communication, fluency and hearing disabilities.
  3. Developing and establishing effective augmentative and alternative communication techniques and strategies, including selecting, prescribing and dispensing of aids and devices as identified by State Practice Acts; and training individuals, their family members/caregivers, and other communication partners in their use.
  4. Establishing effective use of appropriate prosthetic/adaptive devices for speaking.
  5. Providing rehabilitation services for the auditory system, and related counseling services to individuals with hearing loss and to their family members/caregivers. For further details, please see CMS IOM Publication 100-02, _Medicare Benefit Policy Manual_ , Chapter 15, Section 220, referenced in the CMS National Coverage Policy section of this policy.
  6. Providing interventions for individuals with central auditory processing disorders; and/or
  7. Modification or training in use of a voice prosthetic. Modifications in a voice prosthetic to supplement oral speech would be appropriate and should be carried out by a speech-language pathologist. The patient is seen for sizing, fitting, placement or replacement and training of the voice prosthetic.

**Speech/hearing therapy (group)**

For the purpose of performing group therapy, a group is defined as two or more
individuals receiving active therapy, Please see CMS IOM 100-02, _Medicare
Benefit Policy Manual_ , Chapter 15, Section 230 for more information on group
SLP services.

**Therapeutic services (patient adaptation and training) for the use of
speech-generating devices**

Patient adaptation and training for the use of speech-generating devices
includes the development of operational competence in using a speech-
generating device or aids, to include customizing the features of the device
to meet the specific communication needs of each patient and providing
opportunities for developing skill in all aspects of device use.

**SLP THERAPEUTIC PROCEDURES**

Therapeutic procedures are treatments that attempt to reduce impairments and
improve or maintain function (or prevent further deterioration) through the
application of clinical skills or services. Please see CMS IOM Publication
100-02, _Medicare Benefit Policy Manual_ , Chapter 15 for more information on
documentation for therapeutic interventions.

Services provided concurrently by different types of clinicians may be covered
if separate and distinct goals are documented in the treatment plans.

**Therapeutic exercises**

Therapeutic exercise incorporates rehabilitation principles related to
strengthening, endurance, flexibility, and range of motion. Therapeutic
exercise may be performed with a patient either actively, actively assisted,
or passively participating. Therapeutic exercises may be used to strengthen
muscles (e.g., jaw, tongue, facial).

**Therapeutic activities**

Therapeutic activities involve the use of dynamic activities to improve
functional performance in a progressive manner; e.g., increase in volume of
voice through respiratory activities. They require the skills of a clinician
and are designed to address a specific functional need of the patient. Please
see CMS IOM Pub 100-02, _Medicare Benefit Policy Manual_ , Chapter 8, Section
30.2.2.1 and Section 30.4.1.2 for more information.

**Cognitive skills development**

This service describes interventions used to improve, maintain, or prevent
further deterioration of cognitive skills, (e.g., attention, memory, problem
solving) with direct (one-on-one) patient contact by the clinician. It may be
medically necessary for patients with acquired cognitive impairments from head
trauma, acute neurological events (including cerebrovascular accidents), or
other neurological disease.

**Sensory integrative techniques**

This activity focuses on sensory integrative techniques to enhance sensory
processing and to promote adaptive responses to environmental demands, with
direct (one-on-one) patient contact by the clinician. Please see CMS IOM
100-02, _Medicare Benefit Policy Manual_ , Chapter 15, Section 230 for more
information. An example is a patient with several oral problems secondary to a
stroke; the sensory integrative techniques used to facilitate speech might
include flossing or brushing techniques.

**Self-care/home management training**

This training includes activities of daily living (ADL) and compensatory
training, meal preparation, safety procedures, and instructions in use of
adaptive equipment, direct one-on-one contact by the clinician. Please see CMS
IOM 100-02, _Medicare Benefit Policy Manual_ , Chapter 15, Section 220 for
more information.

**Limitations**

The following are considered not reasonable and necessary:

  1. For information regarding therapy performed repetitively to maintain a level of function, please see CMS IOM Publication 100-02, _Medicare Benefit Policy Manual_ , Chapter 8; Section 30; Chapter 12, Section 10; and Chapter 15, Sections 220 and 230.
  2. Please see CMS IOM 100-02, _Medicare Benefit Policy Manual_ , Chapter 15, Section 230.3.D for information regarding screening assessments.
  3. Please see CMS IOM 100-02, Chapter 15, Section 230.3.D for information regarding routine screening for hearing acuity or evaluations.
  4. Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument is considered a screening service. Please see CMS IOM Medicare Benefit Policy Manual, Chapter 15, Section 80.2 regarding psychological and neuropsychological tests.

**Notice:** Services performed for any given diagnosis must meet all of the
indications and limitations stated in this policy, the general requirements
for medical necessity as stated in CMS payment policy manuals, any and all
existing CMS national coverage determinations, and all Medicare payment rules.

The redetermination process may be utilized for consideration of services
performed outside of the reasonable and necessary requirements in this LCD.