how to determine medical necessity for speech services for medicare

Medicare Guidelines for Speech Therapy For Part B to cover speech therapy, your doctor must certify that it’s medically necessary and have a treatment plan ready. Medicare will cover 80% of the cost, you’ll be responsible for the remaining 20% unless you have a Medicare Supplement plan to cover the coinsurance.

Full Answer

Are speech and language services considered medical necessity?

Although there may not be one standard or generally accepted definition for medical necessity, the following information can help support arguments that speech, language, and hearing services meet medical necessity criteria. How Is Medical Necessity Defined?

How does Medicare define “medical necessity?

Medicare defines “medical necessity” as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. CMS has the power under the Social Security Act to determine, on a case-by-case basis, if the method of treating a patient is reasonable and necessary.

When is a medical necessity meeting medical necessity?

Loss of hearing, impaired speech and language, and swallowing difficulties all reflect an impairment of the normal state, and services to treat such impairment must be regarded as meeting medical necessity.

How do you write medical necessity for services reported?

To better support medical necessity for services reported, you should apply the following principles: 1. List the principal diagnosis, condition, problem, or other reason for the medical service or procedure. 2. Assign the code to the highest level of specificity.

What diagnosis will cover speech therapy?

Speech, language, hearing, and/or related disorders: Diagnosis—such as sensorineural hearing loss, expressive aphasia, or dysarthria—established by the audiologist or speech-language pathologist.

Why is speech therapy medically necessary?

Audiology and speech-language pathology services and devices are medically necessary to prevent, identify, evaluate, and treat speech-language, swallowing, cognitive-communication, hearing, and balance disorders.

Does Medicare cover cognitive speech therapy?

Medicare covers medically necessary speech therapy services. There's no longer a limit on how long you can receive these services in a calendar year. Speech therapy can help improve necessary skills such as speech and language abilities, as well as swallowing.

Can an SLP bill Medicare directly?

Enrollment will allow SLPs in private practice to bill Medicare and receive direct payment for their services. Previously, the Medicare program could only pay SLP services if an institution, physician or nonphysician practitioner billed them.

What is speech therapy considered?

Speech therapy assesses and treats speech disorders and communication problems. It helps people develop skills like comprehension, clarity, voice, fluency and sound production. Speech therapy can treat childhood speech disorders or adult speech impairments caused by stroke, brain injury or other conditions.

How do you get referred to a speech therapist?

How to find a speech and language therapist. If you think you, or your child or relative needs to see a speech and language therapist ask your GP, district nurse, health visitor, your child's nursery staff or teacher for a referral. You can also refer yourself to your local speech and language therapy service.

Does Medicare cover speech therapy for dementia patients?

National and local Medicare policy statements clearly support coverage of cognitive therapy services provided by speech-language pathologists.

Does Medicare cover speech therapy for patients with dysphagia?

Speech-language pathology services are covered under Medicare for the treatment of dysphagia, regardless of the presence of a communication disability. The Medicare Benefit Policy Manual , Chapter 15, "Covered Medical and Other Health Services," §§220 and 230.3.

Is 92507 covered by Medicare?

Use 92507 for training and modification of voice prostheses. Medicare won't pay for this code because it is considered bundled with any other speech-language pathology service provided on the same day. SLPs may not separately bill for non-speech-generating device services alone.

How do I bill a Medicare speech pathologist?

SLPs may use 97000 series CPT codes—if appropriate. Under Medicare, SLPs may use CPT codes 97129 (cognitive function intervention, initial 15 minutes) and 97130 (cognitive function intervention, each additional 15 minutes) when treating cognitive disorders.

What Does Medicare pay for speech?

outpatient speech-language pathology services if your doctor or other health care provider certifies you need it. After you meet the Part B deductible, you pay 20% of the Medicare-approved amount.

What is the taxonomy code for speech-language pathology?

Taxonomy code for speech-language pathologists: 235Z00000X.

What is MassHealth's criteria for speech therapy?

MassHealth considers multiple criteria when determining whether speech-language therapy services are a medical necessity . MassHealth bases its determination on clinical documentation that demonstrates the potential for measurable and objective progress and the potential impact of factors that would complicate or affect the ecacy of treatment. These criteria include, but are not limited to, those listed below.

What are the guidelines for speech therapy?

These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information MassHealth needs to determine if medical necessity for speech-language therapy services performed in outpatient and home settings are medically necessary. These Guidelines are based on generally accepted standards of practice, review of medical literature, and federal and state policies and laws applicable to Medicaid programs.

What is speech language therapy?

Speech-language therapy services are defined as those services necessary for the diagnosis or evaluation and treatment of communication disorders that result from swallowing (dysphagia), speech-language, and cognitive-communication disorders. Communication disorders are those that affect speech sound production, resonance, voice, fluency, language, and cognition. Speech-language therapy services are designed to improve, develop, correct, rehabilitate, or prevent the worsening of communication and swallowing skills that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, developmental conditions, or injuries. Potential etiologies of communication and swallowing disorders include neonatal problems, developmental disabilities, auditory problems, oral, pharyngeal, and laryngeal anomalies, respiratory compromise, neurological disease or dysfunction, psychiatric disorders, and genetic disorders.

Identifying the Need for Services (Screening and Assessment)

A screening is a brief pass/fail procedure to identify individuals who require further assessment or referral to other professional and/or medical services.

Determining Medical Necessity

Determining medical necessity involves considering whether a service is essential and appropriate to the diagnosis and treatment of an illness, injury, or disease. Disease is defined as “an impairment of the normal state” (U.S. National Library of Medicine).

Admission and Discharge Criteria

Admission to audiology or speech-language pathology services is based on referral or self-referral. Criteria for delivering medically necessary services include one or more of the following:

Clinical Coverage

The National Association of Insurance Commissioners' (NAIC) Glossary of Health Insurance and Medical Terms [PDF] defines the term rehabilitative services as follows:

General Information

CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Article Guidance

Medical records must support medical necessity of therapy services provided e.g., Are the services appropriate for the patient’s condition and do the services require the skills and knowledge of a qualified clinician? For detailed guidance, view the CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 220-230.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.

General Information

CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Article Guidance

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.

What is medical necessity?

The APTA’s definition of medical necessity (as detailed in this source) addresses the authority, purpose, scope, evidence, and value of the provided treatment. Per the APTA, physical therapy treatment is medically necessary if: A licensed PT determines it is so based on an evaluation;

Why is documentation important in medical care?

Documentation is a cornerstone of ensuring not only high care standards, but also accurate payment—and keeping it defensible it is the key to documenting for medical necessity.

Why is defensible documentation important?

Truly defensible documentation is thorough, easy for any provider to digest, and can help prove that a treatment was medically necessary by virtue of being —well—defensible.

What is the purpose of the type, amount, and duration of the therapy?

The type, amount, and duration of the therapy helps a patient improve function, minimize loss of function, or decrease risk of injury (or disease).

Is APTA medical necessity strict?

The APTA’s definition of medical necessity is actually a little more strict than CMS’s—but that’s not necessarily a bad thing. The more thorough your documentation, the better. And if you adhere to the most stringent standards of medical necessity, your chances for claim denials drop substantially.

How Is Medical Necessity defined?

Documentation Is Needed to Establish Medical Necessity

• Relevant documentation for establishing medical necessity may include the following: 1. Medical history:Pertinent medical history that influences the speech, language, and hearing treatment, brief description of functional status, and relevant prior treatment. 2. Speech, language, hearing, and/or related disorders:Diagnosis—such as sensorineural he...

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Managing Denials For Services Determined Not Medically Necessary

Identifying The Need For Services

Determining Medical Necessity

• Determining medical necessity involves considering whether a service is essential and appropriate to the diagnosis and treatment of an illness, injury, or disease. Diseaseis defined as “an impairment of the normal state” (U.S. National Library of Medicine). Loss of hearing or balance, impaired speech and language, and swallowing difficulties all re...

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Admission and Discharge Criteria

Clinical Coverage