LCD L34563: Home Health Speech-Language Pathology

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.

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