Speech Language Pathology services are those services necessary for the
diagnosis and treatment of speech, language and cognitive communication
disorders which result in communication disabilities. Speech Language
Pathology also includes evaluation and treatment of swallowing.  
  
Speech Language Pathology services are part of a constellation of skilled
services as described by the Centers for Medicare and Medicaid Services (CMS)
Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7,
40.2.3. Acquired etiologies include but are not limited to stroke, brain
tumor, traumatic brain, anoxic or toxic encephalopathy, and nondegenerative
and degenerative neurologic diseases (including the dementias). Speech
Language Pathologists (SLPs) use the clinical history, cognitive/language
examination and a variety of evaluations to characterize individuals with
impairments, activity limitations, disabilities and participation
restrictions. Impairments, functional limitations and disabilities thus
identified are then addressed by the design and implementation of therapeutic
intervention tailored to the specific needs of the individual patient. The
specific interventions most commonly utilized are tasks/exercises to improve,
maintain, train or retrain speech/language, cognitive/memory skills,
swallowing skills and overall communication skills; either verbal or non-
verbal so the individual can communicate and function as effectively as
possible with daily activities. In order to facilitate increased participation
in life, interventions may also include individualized communication partner
training and education in order to help the individual achieve relevant
personal goals appropriate to his or her cultural and/or language community.  
  
For outpatient settings, references to "physicians" throughout this policy
include the following non-physician practitioners (NPPs): nurse practitioners
(NPs), clinical nurse specialists (CNSs) and physician assistants (PAs). Such
NPPs may certify, order and establish the plan of care for Speech Language
Pathology and dysphagia services by SLPs as authorized by State law.

The SLP assesses a patient and develops a plan for treatment as described by
CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter
15, 230.3.

**Restorative/Rehabilitative therapy**  
  
Restorative / Rehabilitative therapy is intended for patients for whom the
goal of therapy is to reverse some loss of function as described in CMS
Internet-Only Manual Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15,
220.2.  
  
 **Maintenance therapy**  
  
Maintenance therapy is intended for patients for whom the goal of treatment is
to slow or prevent deterioration in function as described in CMS Internet-Only
Manual Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 220.2.  
  
 **Evaluation/Re-evaluation**  
  
Evaluation is a comprehensive service that requires professional skills to
make clinical judgments about conditions for which services are indicated
based on objective measurements and subjective evaluations of patient's
performance and functional abilities. Evaluation is warranted, e.g., for a new
diagnosis or when a condition is treated in a new provider setting. These
evaluative judgments are essential to development of the plan of care (POC),
including goals and the selection of interventions. The time spent in the
evaluation does not also count as treatment time.  
  
Re-evaluation is periodically indicated during an episode of care when the
professional assessment of a clinician indicates a significant improvement,
decline, or change in the patient's condition or functional status that was
not anticipated in the POC. Some regulations and State Practice Acts require
re-evaluation at specific intervals. A re-evaluation is focused on evaluation
of progress toward current goals and making a professional judgment about
continued care, modifying goals and/or treatment or terminating services. Re-
evaluation requires the same professional skills as an evaluation.  
  
 **1\. Laryngoscopy, flexible or rigid telescopic, with stroboscopy**  
  
Flexible nasoendoscopy or rigid oral endoscopy is performed using a strobe
light correlated to voice fold vibration, which permits vocal tract structures
to be visualized in an apparent slow-motion format in order to assess the
effect of pathology on the process of voicing and to determine appropriate
therapy strategies.  
  
 **2** **. Modification or training in use of voice prosthetic**  
  
Modifications in voice prosthetic to supplement oral speech would be
appropriate and should be carried out by a SLP. The patient is seen for
sizing, fitting, placement or replacement and training of the voice
prosthetic.  
  
 **3\. Treatment of speech, language, voice, communication, and/or auditory
processing disorder; individual**  
  
Speech/hearing therapy is the treatment/intervention, (e.g., prevention,
restoration, amelioration, and compensation) and follow-up service for
disorders of speech, articulation, fluency, voice, and language skills as well
as for impairments of cognition, language and pragmatics found in cognitive
communication disorders.

These services may include:

a. Providing consultation, counseling, and making referrals when appropriate;

b. Providing education, training and support to family members/caregivers and
other communication partners of individuals with speech, voice, language,
fluency, hearing, cognitive communication disorders and swallowing disorders;

c. 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;

d. Selecting, fitting, and establishing effective use of appropriate
prosthetic/adaptive devices for speaking;

e. Providing audiologic rehabilitation, that is a facilitative process that
provides intervention to address the impairments, activity limitations,
participation restrictions and possible environmental and personal factors
that may affect the communication, functional health, and well-being of
persons with hearing impairment or by others who participate with them in
those activities, including related counseling services to individuals with
hearing loss and to their family members/caregivers, and /or;

f. Providing interventions for individuals with central auditory processing
disorders.

Treatment may include individualized communication/ partner education and
training appropriate to the individual's cultural and language community.  
  
Modifications in voice prosthetic to supplement oral speech would be
appropriate and should be carried out by a SLP. The patient is seen for
sizing, fitting, placement or replacement and training of the voice
prosthetic.  
  
 **4\. Treatment of speech, language, voice, communication, and/or auditory
processing disorder; group, 2 or more individuals  **  
  
A group for the purpose of performing group therapy will be defined as:

a. Two or more patients per therapy receiving active therapy but not 1-on-1
treatment, and;

b. The patients may be performing the same therapy or a different therapy but
the SLP is instructing all the patients in the group.

**5\. Nasopharyngoscopy with endoscope (separate procedure)  **  
  
Nasopharyngoscopy with endoscope is the visualization of the nasopharynx and
vocal tract during speech production with an endoscope to assess and treat
patients with resonance and/or aeromechanical disorders.  
  
 **6\. Nasal Function Studies**  
  
Nasometry assessment is an instrumental assessment of resonance. This
assessment provides numbers that represent a ratio between oral resonance and
nasal resonance during production of specific syllables, phrases, and reading
passages. Normative data is available so that a patient's scores can be
interpreted relative to normal. Nasometry helps quantify hypernasality and
hyponasality. It also provides a baseline for measuring change following
management-therapeutic or surgical.  
  
 **7\. Laryngeal function studies**  
  
Laryngeal function studies are the acoustic and aerodynamic measures used to
evaluate vocal function.  
  
 **8\. Evaluation of speech fluency**  
  
This evaluation is the identification, assessment, and diagnosis of the
following disorders:

\- Fluency (e.g., stuttering, cluttering)

**9\. Evaluation of speech sound production**  
  
This evaluation is the identification, assessment, and diagnosis of the
following disorders:

\- Speech sound production (e.g., articulation, phonological process, apraxia,
dysarthria)

**10\. Evaluation of speech sound production with evaluation of language
comprehension and expression**  
  
This evaluation is the identification, assessment, and diagnosis of the
following disorders:

\- Speech/sound production (e.g., articulation, phonological process, apraxia,
dysarthria)  
\- Language skills (e.g., morphology, syntax, semantics, and pragmatics; also
including disorders of receptive and expressive communication in oral,
written, graphic, and manual modalities)

**11\. Behavioral and qualitative analysis of voice and resonance**  
  
This evaluation is the identification, assessment, and diagnosis of the
following disorders:

\- Voice and resonance disorders (e.g., dysphonia, aphonia, laryngospasm,
dystonia, hypernasality, hyponasality)

**12\. Treatment of swallowing dysfunction and/or oral function for feeding**  
  
Treatment of swallowing dysfunction involves the treatment for impairments
and/or functional limitations of mastication (i.e., chewing), and/or
swallowing (including preparatory, oral, and pharyngeal phases). Swallowing or
oral function therapy may also involve indirect treatment to include
recommendations regarding therapeutic diet, compensatory strategies/techniques
and instructions to facilitate swallowing.  
  
 **13\. Evaluation for use and/or fitting of voice prosthetic device to
supplement oral speech**  
  
The patient is evaluated for a voice prosthetic. The patient's ability to
perform the mechanics necessary to provide voice, care and cleaning of the
unit are evaluated, as well as the patient's preference for the unit (examples
of voice prosthetics are tracheoesophageal valves, electrolarynges, speaking
valves, and voice amplifiers).  
  
Some of these devices are directly attached to the patient and some are not.
They amplify a weak or inaudible voice and supply voice for a non-verbal
patient. The voice prosthetic allows the patient to use his own vocal
production to communicate to the other people.  
  
**14\. Evaluation for prescription of non-speech-generating augmentative and
alternative communication device, face-to-face with the patient; first hour;
Each additional 30 minutes**  
  
Evaluation of patients who are non-verbal or who do not have the capacity for
verbal communication, that may need augmented communication devices for
communication purposes. Augmented communication devices may include the use of
a computer device, book communication, pad/writing tools, etc.  
  
**15\. Therapeutic service(s) for the use of non-speech generating device
(SGD), including programming and modification**  
  
Services to provide treatment of patients who are non-verbal or who do not
have the capacity for verbal communication, that may need augmented
communication devices for communication purposes. Augmented communication
devices may include the use of a computer device, book communication,
pad/writing tools, etc.  
  
**16\. Evaluation for prescription for speech-generating augmentative and
alternating communication device, face-to-face with the patient; first hour;
Each additional 30 minutes**  
  
Evaluation of a patient for prescription of SGDs includes evaluation of
language comprehension and production across modalities: written, spoken, and
gestural. This may also include evaluation of motor skills and nonverbal
communication strategies (e.g., words, pictures, and vocalizations).
Evaluation includes the ability to operate and effectively use a SGD or aid.
Prior to the delivery of the SGD, the patient has had a formal evaluation of
their cognitive and communication abilities by a SLP.  
  
 **17\. Re-evaluation of a patient using SGDs**  
  
Re-evaluation of the patient using SGDs or aids to supplement oral speech,
assess the need for continued use or identify the need for changes in
objectives.  
  
 **18\. Therapeutic services for the use of SGD, including programming and
modification**  
  
Patient adaptation and training for use of SGDs includes the development of
operational competence in using a SGD 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.  
  
 **19\. Evaluation of oral and pharyngeal swallowing function**  
  
Clinical evaluation of swallowing function is the evaluation of oropharyngeal
swallowing dysfunction including the phases of oral preparatory,
oral/voluntary and pharyngeal in reference to problems in the oral cavity and
pharynx.  
  
The bedside clinical examination may include:

a. History of patient's disorder and awareness of swallowing disorder, and
indications of localization and nature of disorder

b. Medical status including nutritional and respiratory status

c. Oral structures (lips, tongue, jaw, hard, and soft palate, oral pharynx,
teeth, mucosa)

d. Pharyngeal function; swallow initiation; impression of signs of aspiration
such as coughing or wet-gurgly voice

e. Laryngeal function; laryngeal elevation during swallow; coordination of
respiration and swallowing; airway protection

f. Oral bolus manipulation and transport through pharyngeal and upper
esophagus

g. Ability to follow directions (alertness)

h. Interventions used to facilitate safe swallow (compensatory strategies such
as chin tuck, dietary changes, etc.)

The clinical examination can be divided into 2 phases:

a. The pre-swallowing assessment/preparatory examination with no swallow, and;

b. The initial swallow examination with actual swallow while physiology is
observed.

**Note:** Based on the findings of the clinical evaluation, an instrumental
examination may or may not be recommended. Despite positive clinical findings
there are times when an instrumental examination may not be indicated (e.g.,
the patient is too medically unstable to tolerate a procedure, the patient is
unable to cooperate or participate in an instrumental exam; in the SLPs
judgment, the instrumental exam would not change the clinical management of
the patient). In addition, because of the documented limitations of the
clinical evaluation of swallowing, there may be scenarios where despite a
negative clinical examination an instrumental examination may still be
indicated. In these cases, information supporting the medical necessity of the
instrumental examination should be documented in the medical records.  
  
 **20\. Motion fluoroscopic evaluation of swallowing function by cine or video
recording**  
  
Evaluation of swallowing involving swallowing of radio-opaque materials is the
evaluation of oropharyngeal and upper digestive swallowing dysfunction
including bolus coordination and transport during deglutition, airway
protection, the benefit of compensatory strategies and effective swallowing.
The SLP must be assured that the patient is alert and has the ability to
follow directions.

Guidance for the appropriate supervision of this study is given in the CMS
Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15,
230.3.  
  
 **Note:** Diagnostic radiographic studies are recommended when results of the
bedside or clinical evaluation are inconclusive or suggest dysphagia and/or
aspiration.  
  
**21\. Flexible endoscopic evaluation of swallowing by cine or video
recording**  
  
An endoscopic evaluation of swallowing (FEES) involves placement of a flexible
endoscope transnasally to the hypopharynx. The procedure permits direct
visualization of anatomy as well as an assessment of amplitude,
speed/briskness, and symmetry of movement of the velopharyngeal sphincter,
base of tongue, pharynx, and larynx. Sensation is assessed by noting the
reaction of the patient to the presence of the endoscope. Findings include
briskness of swallow initiation, timing of bolus flow and swallow initiation,
adequacy of bolus driving/clearing forces, adequacy of velar and laryngeal
valving forces, penetration and/or aspiration before or after the swallow, and
presence of hypopharyngeal reflux.  
  
The skills and competencies required of clinicians providing this service are
described in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit
Policy Manual, Chapter 15, 230.3.  
  
 **22\. Flexible  endoscopic evaluation, laryngeal sensory testing by cine or
video recording**  
  
An endoscopic evaluation of swallowing with sensory testing is the performance
of a FEES with the incorporation of sensory testing. The sensory evaluation is
completed by delivering pulses of air at sequential pressures to elicit the
laryngeal adductor reflex. A sensory threshold is thus established.  
  
Motor evaluation is completed by giving various food items with different
consistencies while factors such as oral transit time, inhibition of
swallowing, laryngeal elevation, spillage, residue, condition of swallow,
laryngeal closure, reflux, aspiration, and ability to clear residue are
monitored. The entire procedure may be done at bedside. The use of anesthesia
may interfere with the sensory test and is usually not indicated.  
  
**Note:** Other instrumental assessments may be indicated to study swallowing.
The appropriateness of the assessment procedure will be based on the nature of
the disorder and standard of practice.  
  
 **23\. Flexible  endoscopic evaluation of swallowing and laryngeal sensory
testing by cine or video recording **  
  
Flexible endoscopic evaluation of swallowing and laryngeal sensory testing
(FEESST) is using a flexible endoscope in the evaluation of swallowing and
laryngeal sensory testing by cine or video recording. Special equipment
includes a sensory stimulator that allows quantification of stimuli. Sensory
evaluation is complete by delivering pulses of air sequentially increased to
elicit the laryngeal adductor reflex.

**24\. Evaluation of  auditory rehabilitation status, first hour; Each
additional 15 minutes; Auditory rehabilitation; prelingual hearing loss;
Auditory rehabilitation; post lingual hearing loss **  
  
Auditory rehabilitation consists of treatment that focuses on comprehension,
and production of language in oral, signed or written modalities; speech and
voice production, auditory training, speech reading, multimodal (e.g., visual,
auditory-visual, and tactile) training, communication strategies, education
and counseling. In determining the necessity for treatment, the patient's
performance in both clinical and natural environment should be considered.  
  
Auditory rehabilitation following cochlear implant includes hearing, and
therapeutic services with or without speech processor programming. This may
include:

a. Extensive auditory rehabilitation therapy for patients with cochlear
implants focusing on audition, cognition, language and speech skills

b. Family member or caregiver training for auditory verbal techniques

c. Improving the patient's auditory skills pertaining to the suprasegmental
aspects

d. Improving the patient's ability to discriminate and exhibit improvements in
patient's speech (manner, place and voicing)

**Note:** Speech processor programming is usually performed by an audiologist.  
  
 **25\. Cholinesterase inhibitor challenge test for myasthenia gravis**  
  
The role of the SLP is to assess the patient's speech characteristics (e.g.,
dysarthria, intensity, voice quality, strength, resonance and endurance in
isolated word production task, conversation, and speech) during cholinesterase
inhibitor challenge testing.  
  
 **26\. Assessment of aphasia**  
  
Evaluation, assessment, diagnosis, and identification of a communication
disorder characterized by complete or partial impairment of language
comprehension, formulation and use; excluding disorders associated with
primary sensory, general mental deterioration or psychiatric disorders by
standardized or informal measures.

**27.** **Developmental** **testing**

This includes assessment of motor, language, social, adaptive and/or cognitive
functioning by standardized developmental instruments with interpretation and
report.

**28\. Neurobehavioral status exam**  
  
This is a clinical assessment of thinking, reasoning and judgment (e.g.,
acquired knowledge, attention, language, memory, planning and problem solving,
and visual spatial abilities) with interpretation and report.  
  
 **29\. Standardized cognitive performance testing**  
  
Evaluate abilities of executive (cognitive) function including: assessment of
learning abilities, memory and working memory, abstract thought, language, and
attention.  
  
 **30\. Group therapy for dysphagia**  
  
Group therapy can be beneficial for dysphagia patients. Dysphagia patients are
all working on aspiration precautions, diet modification/advancement and
similar compensatory swallowing techniques, i.e., cues for small bites/sips,
repeat swallows, throat clearing, chin tuck, head turns, slow pace and for
carryover of skills practiced individually in therapy. As with other group
therapies, dysphagia therapy patients often need to do a variety of
strengthening/range of motion (ROM)/coordination exercises (oral motor,
pharyngeal strengthening, breathing support exercises) regardless of the
degree of impairment. Therefore, whether a patient is nothing by mouth (NPO)
or on a feeding tube and being transitioned to an oral diet or on a mechanical
soft with nectar thick liquid diet, these patients can in fact be grouped
together and achieve functional outcomes.  
  
 **31\. Development of cognitive skills**  
  
This is the developing or restoring of cognitive status (alertness,
orientation, attention, memory, problem solving, recall, affect, reasoning,
judgment, organization, and retention) and informal assessment/observation of
cognitive abilities necessary for performing daily activities.  
  
 **32\. Sensory Integrative Techniques**  
  
This modality may be used for patients needing oral sensory stimulation. The
use of sensory integrative techniques is considered reasonable and necessary
when patients must develop adaptive skills for sensory processing. When there
has been a disruption of the auditory, vestibular, proprioceptive, tactile
and/or visual system, interventions are required to assist the patient in
remaining functional in their environment. The loss of sensory systems often
compromises the safety of the patient; therefore, therapy should provide
adaptations that allow the patient to interact with their environment that
promotes well-being.  
  
 **33\. Self-care/home management training**  
  
Self-care/home and community reintegration management training includes but is
not limited to compensatory training for life participation in communication
situations in both home and community environments, meal preparation, safety
procedures, and instructions in use of assistive technology
methods/devices/adaptive equipment.