(Medicare Benefit Policy Manual)

Occupational therapy may include vocational and prevocational assessment and training.  When services provided by an occupational therapist are related solely to specific employment opportunities, work skills, or work settings, they are not reasonable or necessary for the diagnosis or treatment of an illness or injury and are not covered.  However, A/B MACs (A), (B), and (HHH)  exercise care in applying this exclusion, because the assessment of level of function and the teaching of compensatory techniques to improve the level of function, especially in activities of daily living, are services which occupational therapists provide for both vocational and nonvocational purposes.  For example, an assessment of sitting and standing tolerance might be nonvocationa l for a mother of young children or a retired individual living alone, but could also be a vocational test for a sales clerk.  Training an amputee in the use of prosthesis for telephoning is necessary for everyday activities as well as for employment purposes.  Major changes in life style may be mandatory for an individual with a substantial disability.  The techniques of adjustment cannot be considered exclusively vocational or nonvocational.   230.3 - Practice of Speech -Language Pathology  (Rev. 106, Issued: 04- 24-09, Effective: 07 -01-09, Implementation: 07- 06-09)  A.  General   Speech -language pathology services are those services provided within the scope of practice of speech -language pathologists and necessary for the diagnosis and treatment of speech and language disorders, which result in communication disabilities and for t he diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presence of a communication disability.  (See Pub. 100- 03, chapter 1, 170.3)  See section 230.4 of this chapter for benefit policies on speech- language pathologists in private practice (SLPP). See Pub. 100- 08, Medicare Program Integrity Manual, chapter 10, section 12.4.14 for policy on enrollment in an SLPP.   B.  Qualified Speech -Language Pathologist Defined   A qualified speech -language pathologist for program coverage purposes meets one of the following requirements:    The education and experience requirements for a Certificate of Clinical Competence in (speech -language pathology) granted by the American Speech-Language Hearing Association; or    Meets the educational requirements for certification and is in the process of accumulating the supervised experience required for certification.  For outpatient speech- language pathology services that are provided incident to the services of physicians/NPPs, the requirement for speech- language pathology licensure does not apply; all other personnel qualifications do apply.  Therefore, qualified personnel providing speech- language pathology services incident  to the services of a physician/NPP must meet the above qualifications.  C.  Services of Speech -Language Pathology Support Personnel   Services of speech -language pathology assistants are not recognized for Medicare coverage.  Services provided by speech -language pathology assistants, even if they are licensed to provide services in their states, will be considered unskilled services and denied as not reasonable and necessary if they are billed as therapy services.  Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare.  Although an aide may help the therapist by providing unskilled services, those services are not covered by Medicare and sha ll be denied as not reasonable and necessary if they are billed as therapy services.  D.  Application of Medicare Guidelines to Speech -Language Pathology Services   1.  Evaluation Services   Speech -language pathology evaluation services are covered if they are reasonable and necessary and not excluded as routine screening by 1862(a)(7)  of the Act.  The speech -language pathologist employs a variety of formal and informal speech, language, and dysphagia assessment tests to ascertain the type, causal factor(s), and severity of the speech and language or swallowing disorders.  Reevaluation of patients for whom speech, language and swallowing were previously contraindicated is covered only if the patient exhibits a change in medical condition.  However, monthly reevaluations; e.g., a Western Aphasia Battery, for a patient undergoing a rehabilitative speech- language pathology program, are considered a part of the treatment session and shall not be covered as a separate evaluation for billing purposes.  Although hearing screening by the speech-language pathologist may be part of an evaluation, it is not billable as a separate service.  2.  Therapeutic Services   The following are examples of common medical disorders and resulting communication deficits, which may necessitate active rehabilitative therapy.  This list is not all-inclusive:  Cerebrovascular disease such as cerebral vascular accidents presenting with dysphagia, aphasia/dysphasia, apraxia, and dysarthria;  Neurological disease such as Parkinsonism or Multiple Sclerosis with dysarthria, dysphagia, inadequate respiratory volume/control, or voice disorder; or  Laryngeal carcinoma requiring laryngectomy resulting in aphonia.  3.  Impairments of the Auditory System   The terms, aural rehabilitation, auditory rehabilitation, auditory processing, lipreading and speech reading are among the terms used to describe covered services related to perception and comprehension of sound through the auditory system.  See Pub. 100-04, chapter 12, section 30.3 for billing instructions.  For example:   Auditory processing evaluation and treatment may be covered and medically necessary.  Examples include but are not limited to services for certain neurological impairments or the absence of natural auditory stimulation that results in impaired ability to p rocess sound.  Certain auditory processing disorders require diagnostic audiological tests in addition to speech-language pathology evaluation and treatment.   Evaluation and treatment for disorders of the auditory system may be covered and medically necessary, for example, when it has been determined by a speech -language pathologist in collaboration with an audiologist that the hearing impaired beneficiarys cur rent amplification options (hearing aid, other amplification device or cochlear implant) will not sufficiently meet the patients functional communication needs.  Audiologists and speech-language pathologists both evaluate beneficiaries for disorders of the auditory system using different skills and techniques, but only speech-language pathologists may provide treatment.   Assessment for the need for rehabilitation of the auditory system (but not the vestibular system) may be done by a speech language pathologist.  Examples include but are not limited to: evaluation of comprehension and production of language in oral, signed or written modalities, speech and voice production, listening skills, speech reading, communications strategies, and the impact of the hearing loss on the patient/client and family.   Examples of rehabilitation include but are not limited to 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 beneficiarys performance in both clinical and natural environment should be considered.   4.  Dysphagia   Dysphagia, or difficulty in swallowing, can cause food to enter the airway, resulting in coughing, choking, pulmonary problems, aspiration or inadequate nutrition and hydration with resultant weight loss, failure to thrive, pneumonia and death.  It is most  often due to complex neurological and/or structural impairments including head and neck trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, dementias, and encephalopathies.  For these reasons, it is important that only qualified professionals with specific training and experience in this disorder provide evaluation and treatment.   The speech -language pathologist performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques.  The equipment that is used in the examination may be fixed, mobile or portable.  Professional guidelines recommend that the service be provided in a team setting with a physician/NPP who provides supervision of the radiological examination and interpretation of medical conditions revealed in it.   Swallowing assessment and rehabilitation are highly specialized services.  The professional rendering care must have education, experience and demonstrated competencies.  Competencies include but are not limited to: identifying abnormal upper aerodigestive  tract structure and function; conducting an oral, pharyngeal, laryngeal and respiratory function examination as it relates to the functional assessment of swallowing; recommending methods of oral intake and risk precautions; and developing a treatment plan employing appropriate compensations and therapy techniques.   230.4 - Services Furnished by a Therapist in Private Practice (TPP)  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  A.  General   See section 220 of this chapter for definitions.  Therapist refers only to a qualified physical therapist, occupational therapist or speech- language pathologist.  TPP refers to therapists in private practice (qualified physical therapists, occupational the rapists and speech -language pathologists).  In order to qualify to bill Medicare directly as a therapist, each individual must be enrolled as a private practitioner and employed in one of the following practice types: an unincorporated solo practice, unincorporated partnership, unincorporated group practice, physician/NPP group or groups that are not professional corporations, if allowed by state and local law.  Physician/NPP group practices may employ TPP if state and local law permits this employee relationship.   For purposes of this provision, a physician/NPP group practice is defined as one or more physicians/NPPs enrolled with Medicare who may bill as one entity.  For further details on issues concerning enrollment, see the provider enrollment Web site at www.cms.hhs.gov/MedicareProviderSupEnroll and Pub. 100-08, Medicare Program Integrity Manual, chapter15, section 15.4.4.9.  Private practice also includes therapists who are practicing therapy as employees of another supplier, of a professional corporation or other incorporated therapy practice.  Private practice does not include individuals when they are working as employees of an institutional provider.  Services should be furnished in the therapists or groups office or in the patients home.  The office is defined as the location(s) where the practice is operated, in the state(s) where the therapist (and practice, if applicable) is legally authorized to  furnish services, during the hours that the therapist engages in the practice at that location.  If services are furnished in a private practice office space, that space shall be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice.  For descriptions of aquatic therapy in a community center pool see section 220C of this chapter.   Therapists in private practice must be approved as meeting certain requirements, but do not execute a formal provider agreement with the Secretary.   If therapists who have their own Medicare National Provider Identifier (NPI) are employed by therapist groups, physician/NPP groups, or groups that are not professional organizations, the requirement that therapy space be owned, leased, or rented may be satisfied by the group that employs the therapist.  Each therapist employed by a group should enroll as a TPP.  When therapists with a Medicare NPI provide services in the physicians/NPPs office in which they are employed, and bill using their NPI for each therapy service, then the direct supervision requirement for enrolled staff apply.  When the therapist who has a Medicare NPI is employed in a physicians/NPPs office the services are ordinarily billed as services of the therapist, with the therapist identified on the claim as the supplier of services.  However, services of the therapist who has a Medicare NPI may also be billed by the physician/NPP as services incident to the physicians/NPPs service.  (See  230.5 for rules related to therapy services incident to a physician.)  In that case, the physician/NPP is the supplier of service, the NPI of the supervising physician/NPP is reported on the claim with the service and all the rules for both therapy services and incident to services (230.5)  must be followed.   B.  Private Practice Defined   Reference:  Federal Register November, 1998, pages 58863- 58869; 42CFR 410.38(b), 42CFR410.59, 42CFR410.60, 42CFR410.62  The contractor considers a therapist to be in private practice if the therapist maintains office space at his or her own expense and furnishes services only in that space or the patients home.  Or, a therapist is employed by another supplier and furnishes  services in facilities provided at the expense of that supplier.   The therapist need not be in full -time private practice but must be engaged in private practice on a regular basis; i.e., the therapist is recognized as a private practitioner and for that purpose has access to the necessary equipment to provide an adequat e program of therapy.   The therapy services must be provided either by or under the direct supervision of the TPP.  Each TPP should be enrolled as a Medicare provider.  If a therapist is not enrolled, the services of that therapist must be directly supervised by an enrolled ther apist.  Direct supervision requires that the supervising private practice therapist be present in the office suite at the time the service is performed.  These direct supervision requirements apply only in the private practice setting and only for therapis ts and their assistants.  In other outpatient settings, supervision rules differ.  The services of support personnel must be included in the therapists bill.  The supporting personnel, including other therapists, must be W -2 or 1099 employees of the TPP or other qualified employer.