Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 3 - Outpatient Speech-Language Pathology (Speech Therapy) › Rule 23-213-3.3 - Covered Speech-Language Pathology and Audiology Services

Current through June 25, 2024
A. The Division of Medicaid covers
				speech-language pathology and audiology services in the outpatient setting when
				medically necessary, ordered by a physician, physician assistant or nurse
				practitioner, for the diagnosis and treatment of a communication impairment
				and/or swallowing disorder due to disease, trauma, or congenital anomaly and
				prior authorized by a Utilization Management/Quality Improvement Organization
				(UM/QIO), the Division of Medicaid or a designated entity and the following
				requirements are met:
1. The services require
				the knowledge, skill and judgment of a state-licensed speech-language
				pathologist or audiologist.
2. The
				Certificate of Medical Necessity (CMN) for initial referral/order is completed
				by the prescribing provider prior to the speech-language pathology or audiology
				evaluation.
3. The plan of care
				(POC) is developed by a state-licensed speech-language pathologist or
				audiologist.
4. The prescribing
				provider approves the initial/revised POC with a signature and date:
a) Before the initiation of treatment or
				change in treatment, or
b) Within
				thirty (30) calendar days of the verbal order for the initial treatment plan or
				change in treatment.
5.
				The services are rendered as individualized speech language pathology or
				audiology services consistent with the symptomatology/diagnosis and do not
				exceed the beneficiary's needs.
6.
				The services do not duplicate another provider's services including those
				services provided in a school-based setting.
7. The beneficiary presents with one (1) or
				more of the following:
a) Aphagia defined as
				an inability to swallow,
b)
				Aphasia defined as an absence/impairment of the ability to communicate through
				speech, writing, or signs caused by focal damage to the language dominant
				hemisphere of the brain,
c)
				Aphonia defined as an inability to produce sounds from the larynx due to
				excessive muscle tension, paralysis, or disease of the laryngeal nerves,
d) Apraxia defined as an inability
				to form words to speak despite an ability to use facial and oral muscles to
				make sounds,
e) Dysarthria defined
				as defective or difficult speech that involves disturbances in muscular control
				like weakness, lack of coordination, or paralysis of the speech mechanism,
				either oral, lingual, respiratory or pharyngeal muscles, resulting from damage
				to the peripheral or central nervous system,
f) Dysphagia defined as difficulty
				swallowing,
g) Dysphasia defined
				as language impairment from neurodevelopmental disorder or brain lesion,
h) Dysphonia defined as difficulty
				speaking due to impairment of the muscles involving vocal production, and/or
i) Vocal cord dysfunction defined
				as impairment of vocal cord mobility due to functional or structural
				abnormalities resulting from organic or neurological diseases.
8. Risk factors have been
				identified and documented including, but are not limited to:
a) Neurological disorders/dysfunctions, such
				as hearing loss or cerebral palsy,
b) Surgical procedures, such as
				partial/comprehensive/radical laryngectomy, repaired cleft palate, or
				glossectomy,
c) Cognitive
				impairments that affect communication functions, or
d) Medical conditions resulting in
				communication disorders that require restorative therapy including, but not
				limited to:
1) Laryngeal carcinoma requiring
				partial/total largyngectomy that results in dysphonia or aphonia,
2) Traumatic brain injury that may exhibit
				inadequate respiratory volume, apraxia, dysphagia, or dysarthria,
3) Progressive/static neurological
				conditions, such as amyotrophic lateral sclerosis, Parkinson's disease,
				myasthenia gravis, multiple sclerosis, or Huntington's disease,
4) Intellectual disability with disorders of
				dysarthria, dysphagia, apraxia, or aphagia, and/or
5) Cerebrovascular disease, such as
				cerebrovascular accident, presenting with apraxia, aphasia, dysphagia, or
				dysarthria.
9. The type of service requested includes one
				(1) or more of the following:
a) Diagnostic
				and evaluation services:
1) To determine the
				type, causal factors, severity of speech-language or swallowing disorders, and
				the extent of service required to restore functions of speech, language, voice
				fluency, and swallowing, or
2) The
				beneficiary demonstrates changes in functional speech or remission of a medical
				condition that previously contradicted speech-language therapy.
b) Therapeutic services defined as
				services requiring active corrective/restorative therapy, for communication
				disorders that result from:
1) Laryngeal
				carcinoma requiring partial/total largyngectomy that results in aphonia so the
				beneficiary can develop new communication skills through esophageal speech or
				the use of an electrolarynx,
2)
				Cerebrovascular disease, such as cerebrovascular accident, presenting with
				apraxia, aphasia, dysphagia, or dysarthria, or
3) Medical and neurological conditions, like
				traumatic brain injury, Parkinson's disease, or multiple sclerosis, exhibiting
				inadequate respiratory volume/control, aphonia, dysphagia, dysarthria, or
				dysphonia.