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General Occupational Therapy Guidelines


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 and cognitive disorders disorders that which result in communication disabilities, cognitive dysfunction, as well as and for the diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presence of a communication disability. (see Pub 100-03, Chapter 1, section 170.3, for additional information).

See Pub 100-02, Chapter 15, Section 230.3B for requirements and definition for a qualified speech-language pathologist for Medicare coverage.

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 and aide may help a therapist by providing unskilled services, those services are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.

Evaluation Services for speech-language pathology

Speech-language pathology evaluation services are covered if they are reasonable and necessary and not excluded as routine screening by section 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 a separate service.

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.

Impairments of the Auditory System

The terms aural rehabilitation, auditory rehabilitation, auditory processing, lipreading and speechreading are among the terms used to describe covered services realted to perception and comprehension of sound through the auditory system. See Pub 100-04, chapter 12, section 30.3 for billing instruction. 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 process 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 beneficiary’s current amplification options (hearing aide, other amplification device or cochlear implant) will not sufficiently meet the patient’s functional communications needs. Audiologists and speech-language pathologists both evaluate beneficiaries for disorders of the auditory system using different skills and techniques, but only speech-language pathologist 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 beneficiary’s performance in both clinical and natural environment should be considered.

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 related 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.

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