**Abstract:**  
  
This Local Coverage Determination (LCD) describes the coverage and limits of
coverage for speech and language pathology therapy services when billed to
either the Medicare Part A or Part B. This LCD shall not be construed to
expand coverage to services defined as non-covered by National Coverage
Determinations (NCDs).  
  
 **Definitions:**  
  
Rehabilitative therapy includes services designed to address recovery or
improvement in function and, when possible, restoration to a previous level of
health and well-being. (CMS Publication 100-02, _Medicare Benefit Policy
Manual_ , Chapter 15, Section 220.2(C)) and 220.3  
  
MAINTENANCE PROGRAM (MP) means a program established by a therapist that
consists of activities and/or mechanisms that will assist a beneficiary in
maximizing or maintaining the progress he or she has made during therapy or to
prevent or slow further deterioration due to a disease or illness. (CMS
Publication 100-02 _, Medicare Benefit Policy Manual,_ Chapter 15, Section 220
(A)) _  
  
_ **Indications:**  
  
Speech-language pathology services may be considered reasonable and necessary
when the criteria in this LCD, as well as the National Coverage provisions
listed in the related Billing and Coding Article, are met. (Please refer the
Billing and Coding Article A52866) _  
  
_ _Evaluation of Language Disorders:_  
  
The order or referral for the evaluation and any specific testing in areas of
concern should be designated by the referring physician in consultation with
an SLP. The physician's certification of the need for care (e.g., approval of
the plan of care) may substitute for the order. The documentation of the
evaluation or re-evaluation by the SLP should demonstrate that an actual
hands-on assessment occurred to support the medical necessity for
reimbursement of the evaluation or re-evaluation. The documentation should
differentiate between evaluation or re-evaluation and screening. Screening
assessments are noncovered and should not be billed. The initial screening
assessments of patients or regular routine reassessments of patients are not
covered. Evaluations in the absence of signs and symptoms are not covered.  
  
The evaluation should include the beneficiary's history and the onset or
exacerbation date of the current disorder. The history in conjunction with the
current symptoms must establish support for additional treatment. Prior level
of functioning should be documented, as well as current baseline abilities, to
establish the basis for the therapeutic interventions. Evaluations must
include the plan, goals (realistic, long-term, functional, communication
goals) duration of therapy, frequency of therapy, and definition of the type
of service. Diagnostic and assessment testing services to ascertain the type,
causal factor(s) and severity of speech and language disorders, should be
identified during the evaluation.

For information on Re-evaluations please refer to the related Billing and
Coding Article.

Documentation is expected to support the ability of the beneficiary to learn
and retain instruction. Absence of such documentation may result in a denial
of services. If the patient has questionable cognitive skills, a brief
cognitive-communication assessment should be performed in order to establish
the patient's learning ability. The brief cognitive assessment may also
determine the need for more comprehensive cognitive performance testing.

For additional information on Medicare requirements for PT, OT, and Speech-
Language Pathology evaluation and re-evaluation of services see CMS
Publication 100-02, _Medicare Benefit Policy Manual, Chapter 15, Section 220._

  
_Skilled Procedures and Modalities:_

Skilled procedures include:

  * Design of a treatment program addressing the beneficiary's disorder. Continued assessment and analysis during the implementation of the services is expected at regular intervals.  
  

  * Establishment of compensatory skills for communication (e.g., air injection techniques or word finding strategies).  
  

  * Establishment of a hierarchy of speech-language tasks and cueing hat directs a beneficiary toward communication goals.  
  

  * Analysis of actual progress toward goals.  
  

  * Establishment of treatment goals specific to speech dysfunction and designed to specifically address each problem identified in initial assessment.  
  

  * The selection and initial training of a device for augmentative or alternative communication systems.  
  

  * Patient and family training to augment restorative treatment or to establish a maintenance program. Education of staff and family must begin at the time of evaluation.

Documentation is expected to support the ability of the beneficiary to learn
and retain instruction. Absence of such documentation may result in a denial
of services. If the patient has questionable cognitive skills, a brief
cognitive-communication assessment should be performed in order to establish
the patient's learning ability. The brief cognitive assessment may also
determine the need for more comprehensive cognitive performance testing.  
  
_Aural Rehabilitation:  _  
  
Coverage for speech reading is only allowed with documentation that supports a
loss of hearing sensitivity that cannot be corrected with a hearing aid or
amplification. Documentation should also support visual acuity of the
beneficiary sufficient to participate in aural rehabilitation.  
  
Speech reading is considered medically necessary when determined by a licensed
audiologist that the use of a hearing aid or other amplification would not
significantly improve the beneficiary's understanding of speech. Speech
reading training is not medically necessary for beneficiaries who refuse to
wear a hearing aid. Routine screening for hearing acuity or evaluations aimed
at the use of hearing aids is not a covered service.  
  
Determination of the medical necessity for the speech reading will be based on
the following criteria:

  * Documentation of basic hearing evaluation and audiogram;  
  

  * Documentation identifying type and extent of hearing loss;  
  

  * Documentation of adequate cognitive and memory skills;  
  

  * Documentation that visual acuity, with glasses if applicable, is sufficient to allow the beneficiary to participate in the therapy;  
  

  * Documentation of the beneficiary's motivation to participate in therapy in order to improve understanding of speech.

See CMS Publication 100-02, _Medicare Benefit Policy Manual_ , Chapter 15,
Section 230.3.D.3 and the related Billing and Coding Article for more
information on aural rehabilitation.

_Group Therapy:_  
  
Group therapy sessions must meet the individualized plan of treatment
requirement and are not subject to reimbursement if these criteria are not
met. Group therapy coverage for speech reading can be covered (if medically
justified) if the following criteria are met:

  * Services are rendered under an individualized plan of care  
  

  * The group has no more than four group members  
  

  * Group therapy does not represent the entire plan of treatment

_Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy_  
  
This procedure may be used for assessing voice production and vocal function.
It may be performed by qualified speech-language pathologists.  
  
Speech-language pathologists should have evidence that they meet the ASHA
(American Speech-Language--Hearing Association) training requirements as
outlined in the ASHA's _Training Guidelines for Laryngeal
Videoscopy/Stroboscopy_.  
  
**Limitations:**  
  
Following are some examples of interventions which would generally be
considered non-skilled and therefore not covered under Medicare:

  * Non-diagnostic, non-therapeutic, routine, repetitive and reinforcing procedures (e.g., the practicing of word drills without skilled feedback).  
  

  * Procedures which are repetitive and/or that reinforce previously learned material which the beneficiary, staff or family may be instructed to repeat.  
  

  * Procedures which may be effectively carried out with the beneficiary by any non-professional (family or restorative aide) after instruction is completed.   
  

  * Services rendered by a SLP assistant or aide.  
  

  * Provision of practice for use of augmentative or alternative communication systems after being taught their use.  
  

  * Although speech-language pathologists may perform laryngoscopy for the assessment of voice production and vocal function, laryngoscopy for medical diagnostic purposes must be performed by a physician.

Generally, group therapy sessions, except as specified above, are not covered.
Group therapy sessions in social organizations such as the stroke club or lost
cord club are not covered. See the "Indications" section above for information
on when group therapy might be covered.  
  
Speech-language pathology services provided for chronic disorders of memory
and orientation are covered services when significant functional progress is
demonstrated at early stages of the disorder. When functional progress
plateaus, the development of a maintenance program, including training of
caregivers and family members is covered.  
  
Preparation of memory aids such as memory books, memory boards, or
communication books may be covered. Supervision of the use of such aids is not
covered as these services do not require the skills of a qualified therapist.  
  
All SLP services provided by anyone other than an SLP who is licensed or
otherwise authorized by the State in which they practice, including a speech-
language pathology assistant or aide, are not covered.  
  
The following disorders are typically non-covered for the geriatric Medicare
beneficiary:

  * Fluency disorder  
  

  * Conceptual handicap  
  

  * Dysprosody  
  

  * Stuttering and cluttering (except neurogenic stuttering caused by acquired brain damage)  
  

  * Myofunctional disorders, e.g., tongue thrust

Speech-language pathology is considered medically appropriate treatment for
individuals with mental retardation when comorbid disorders such as aphasia or
dysarthria are exhibited.  
  
Speech therapy interventions to instruct the beneficiary in English phrases,
who has a primary language other than English, are not covered. However, when
the primary language of the beneficiary is other than English, speech therapy
interventions in the patient's primary language will be covered within the
parameters of this LCD.  
  
 **Other Comments:**  
  
There may be rare cases of children who fall under criteria specified in this
LCD. Claims for services rendered to children may be covered and approved upon
individual consideration.