Speech-language pathology services are part of a constellation of skilled
rehabilitative services designed to improve or restore cognitive functioning,
communication skills and/or feeding skills following congenital or acquired
disease or injury. Speech-language pathologists (SLPs) use the clinical
history, cognitive/language 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
intervention tailored to the specific needs of the individual patient. Such
services may also be reasonable and necessary when applied to maintain a level
of functioning or prevent or slow further deterioration. Coverage of therapy
services, including speech-language pathology services, is based on an
individual's need for skilled care as described in the CMS Internet-Only
Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, 40.2.3. The
specific interventions most commonly utilized are tasks/exercises to improve,
maintain, train or retrain cognitive/memory skills, feeding skills and overall
communication skills; either verbal or non-verbal so the individual can
communicate and function as effectively as possible with daily activities.  
  
 **Restorative/Rehabilitative therapy**  
  
In evaluating a claim for skilled therapy that is restorative/rehabilitative
(i.e., whose goal and/or purpose is to reverse, in whole or in part, a
previous loss of function), it would be entirely appropriate to consider the
beneficiary's potential for improvement from the services. Skilled therapy
must be reasonably expected to improve the patient's functional capacity or
adaptation to impairments in order to be covered.  
  
 **Maintenance Therapy**  
  
Even if no improvement is expected, under the skilled nursing facility (SNF),
home health (HH), and outpatient (OPT) coverage standards, skilled therapy
services are covered when an individualized assessment of the patient's
condition demonstrates that skilled care is necessary for the performance of a
safe and effective maintenance program to maintain the patient's current
condition or prevent or slow further deterioration. Skilled maintenance
therapy may be covered when the particular patient's special medical
complications or the complexity of the therapy procedures require skilled
care.  
  
 **Maintenance Program**  

Coverage of therapy services, including speech-language pathology services,
for a maintenance program is based on the individual's need for skilled care
in that maintenance program as described in the CMS Internet-Only Manual, Pub.
100-02, Medicare Benefit Policy Manual, Chapter 7, 40.2.1.

**Re-evaluation**  

A re-evaluation would be considered reasonable and necessary for indications
described by the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit
Policy Manual, Chapter 7, 40.2.3.  
  
 **1\. Speech/hearing treatment**  
  
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 aspects of communication:

a. Providing consultation, counseling, and making referrals when appropriate  
  
b. Providing training and support to family members/caregivers and other
communication partners of individuals with speech, voice, language,
communication, fluency, hearing and swallowing disabilities  
  
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 aural rehabilitation and related counseling services to
individuals with hearing loss and to their family members/caregivers  
  
f. Providing interventions for individuals with central auditory processing
disorders

**2\. Evaluation of speech fluency**  
  
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,
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 plan of care. 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.  
  
The evaluation is the identification, assessment, and diagnosis of the
following disorders:

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

**3\. Evaluation of sound production**  
  
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 for example,
with 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,
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 plan of care. 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.  
  
The evaluation is the identification, assessment, and diagnosis of the
following disorders:

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

**4\. Evaluation of speech sound production with evaluation of language
comprehension and expression**  
  
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,
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 plan of care. 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.  
  
The 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)

**5\. Behavioral and qualitative analysis of voice and resonance**  
  
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,
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 plan of care. 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.  
  
The evaluation is the identification, assessment, and diagnosis of the
following disorders:

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

**6\. Speech/Aural rehabilitation following cochlear ear implant**  
  
Aural rehabilitation following cochlear implant includes evaluation or aural
rehabilitation status and 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. Improve patients' auditory skills pertaining to the suprasegmental aspects  
  
d. Improve patients' ability to discriminate and exhibit improvements in
patient's speech (manner, place and voicing)

**  *Note:** Speech processor programming is usually performed by an
audiologist.  
  
 **7\. Clinical evaluation of swallowing function**  
  
The evaluation of oropharyngeal swallowing dysfunction including the phases of
oral preparatory, oral/voluntary and pharyngeal in reference to oral and
motility 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 anatomy/physiology (labial control, lingual control, palatal function)  
  
d. Pharyngeal function  
  
e. Laryngeal function  
  
f. Ability to follow directions (alertness)  
  
g. Interventions used to facilitate normal swallow (compensatory strategies
such as chin tuck, dietary changes, etc.)  
  
h. Identifying symptoms during attempts to swallow

The clinical examination can be divided into 2 phases:

a. The pre-swallowing assessment/preparatory examination with no swallow  
  
b. The initial swallow examination with actual swallow while physiology is
observed

***Note:** Based on the findings of a 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 examination, in the SLPs
judgment, the instrumental examination 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 record.  
  
 **8\. Oral function therapy**  
  
This involves the treatment for impairments/functional limitations of
mastication, the preparatory, oral, and pharyngeal phases of swallowing. The
SLP may make appropriate recommendations (re: diet and compensatory techniques
and instruct in direct/indirect therapies) to facilitate oral motor control
for feeding.  
  
 **9\. Evaluation of patient for prescription of speech-generating devices
(SGDs)**  
  
This includes evaluation of language comprehension and production across
modalities: written, spoken and gestural. May also include evaluation of motor
skills and nonverbal communication strategies (i.e., words, pictures, and
vocalization). Includes evaluation of the ability to operate and effectively
use an SGD or aid.  
  
**10\. Patient adaptation and training for use of  SGDs **  
  
Includes development of operational competence in using an 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
skills in all aspects of device use.  
  
 **11\. Re-evaluation of patient using SGDs**  
  
Re-evaluation of patient using SGDs or aids to supplement oral speech, assess
need for continued use or identify need for changes in objectives.  
  
**12\. 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 (modification of voice
prosthetic would involve programming or reprogramming device to meet the
patient's needs). Patient is seen postoperatively for training of the voice
prosthetic.  
  
 **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\. 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.

**15\. Developmental testing**

 This includes assessment of motor, language, social, adaptive and/or
cognitive functioning by standardized developmental instruments; with
interpretation and report.  
 ** **  
 **16\. Neurobehavioral status exam**  
  
Neurobehavioral status exam (clinical assessment of thinking, reasoning and
judgment, for example- acquired knowledge, attention, memory, visual spatial
abilities, language functions, planning) with interpretation and report.  
  
 **17\. Standardized cognitive performance testing**  
  
Evaluate abilities of executive (cognitive) function including: assessment of
learning abilities, memory and working memory, abstract thought, language, and
attention.  
  
**18\. Therapeutic exercises**  
  
Describes exercises used to strengthen muscles (e.g., jaw, tongue, facial).  
  
 **19\. Therapeutic Activities**  
  
Use of dynamic activities to improve functional performance.  
  
 **20\. Cognitive skills development**  
  
Develop or restore 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.  
  
 **21\. Sensory Integrative Techniques**  
  
This modality may be used for patient's 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.  
  
**22\. Self-care/home management training**  
  
Compensatory training, meal preparation, safety procedures, and instructions
in use of assistive technology devices/adaptive equipment.