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Speech Therapy

 

DESCRIPTION

Speech therapy is the treatment of communication impairment and swallowing disorders. Speech therapy services facilitate the development and maintenance of human communication and swallowing through assessment, diagnosis and rehabilitation.

 

POLICY

Speech therapy services are eligible for coverage provided they meet the criteria stated in this policy. These services are considered medically necessary when used in the treatment of communication impairment or swallowing disorders due to disease, trauma, congenital anomalies or prior therapeutic intervention.

Speech therapy services are considered investigational for dysfunctions that are self-correcting, such as language therapy for young children with natural dysfluency or developmental articulation errors that are self-correcting.

Speech therapy services are not medically necessary for the following conditions:

  • Developmental problems, including, but not limited to, developmental delay;
  • Learning disabilities;
  • Attention disorders;
  • Psychosocial speech delay;
  • Behavioral problems;
  • Conceptual handicap;
  • Mental retardation;
  • Stammering, stuttering.

A speech therapy session is defined as up to one hour of speech therapy (treatment and/or evaluation) on any given day.

Speech therapy sessions must meet all of the following criteria:

  • Treat the needs of a patient who suffers from communication impairment or swallowing disorder, due to disease, trauma, congenital anomalies or prior therapeutic intervention;
  • Achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time;
  • Provide specific, effective and reasonable treatment for the patient's diagnosis and physical condition;
  • Be delivered by a qualified, licensed provider of speech therapy services. A qualified provider is one who is licensed where required and performs within the scope of licensure;
  • Require the judgment, knowledge and skills of a qualified provider of speech therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient.

Certain types of treatment do not generally require the skills of a qualified provider of speech therapy services, such as treatments which maintain function by using routine, repetitions, and reinforced procedures that are neither diagnostic nor therapeutic (for example; practicing word drills for developmental articulation errors) or procedures that may be carried out effectively by the patient, family or caregivers. These services are considered not medically necessary.

 

POLICY EXCEPTIONS

None

 

POLICY GUIDELINES

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

Speech therapy as limited in the Schedule of Benefits and this section is covered up to the Benefit maximum or when maintenance level of therapy is attained (whichever the Member reaches first). A maintenance program consists of activities that preserve the Member's present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Benefits for a maintenance program are not covered.

Inpatient benefits are considered not medically necessary if the hospital admission is solely for the purpose of receiving speech therapy.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

9/1994: Issued

11/1997: Prior authorization required; expanded description of non-covered services

2/14/2002: Investigational definition added

2/27/2002: Prior Authorization and Managed Care Requirements deleted

3/6/2002: Treatment plan submission to BCBSMS requirements before initiation of treatment deleted

5/7/2002: Type of Service and Place of Service deleted

6/23/2004: Policy reviewed, Sources updated

11/19/2004: Code Reference section updated, CPT 92506 added, CPT code 92598 typo should be 92508, ICD-9 procedure code range 93.72-93.75 listed separately, ICD-9 diagnosis code V57.3 added, HCPCS S9128 added

3/21/2006: Coding updated. CPT4 2006 revisions added to policy

4/11/2006: Policy reviewed, no changes

9/18/2006:  Coding updated.  ICD9 2006 revisions added to policy.

6/14/2007: Code Reference section updated per quarterly HCPCS and Category III revisions

9/20/2007: Code Reference section updated. ICD-9 2007 revisions added to policy

9/29/2009: Code Reference section updated. New ICD-9 diagnosis codes 784.42, 784.43, 784.44, 784.51 and 784.59 added to covered table. Deleted statement added to ICD-9 code 784.5. ICD-9 diagnosis code 784.9 deleted from covered due to code was deleted as of 9-30-2006. ICD-9 diagnosis code 787.2 deleted from covered table due to code was deleted as of 90-30-2007. Description revised for ICD-9 code 784.49. Code description revised for ICD-9 diagnosis code V57.3.

06/03/2010:  Policy description and statement unchanged.  Updated the Code Reference section to add the following statement to ICD-9 code 784.59:  "Use to report non-developmental articulation disorder."

03/08/2013: Policy reviewed; no changes.

02/18/2014: Added the following new 2014 CPT codes to the Covered Codes table: 92522 and 92523. Created a Not Medically Necessary Codes table and added the following new 2014 CPT codes: 92521 and 92524.

 

SOURCE(S)

A search of literature was completed through the MEDLINE database for the period of January 1990 through October 1995. The search strategy focused on references containing the following Medical Subject Headings: Speech Therapy.  Research was limited to English-language journals on humans

Hayes Medical Technology Directory

Blue Cross Blue Shield Association policy # 8.03.04

 

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. 

Covered Codes 

Code Number

Description

CPT-4

92506

Evaluation of speech, language, voice, communication, and/or auditory processing (Deleted 12-31-2013)

92507

Treatment of speech, language, voice, communication and/or auditory processing disorder; individual

92508

Treatment of speech, language, voice, communication and/or auditory processing disorder (Includes aural rehabilitation); group, two or more individuals 

92522

Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)

92523

Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)

ICD-9 Procedure

93.72, 93.73, 93.74, 93.75

Speech therapy code range

ICD-9 Diagnosis

784.3

Aphasia

784.41

Aphonia code range

784.42

Dysphonia 

784.43

Hypernasality 

784.44

Hyponasality 

784.49

Other voice and resonance disorders

784.5

Other speech disturbance

784.51

Dysarthria 

784.59

Other speech disturbance (Use to report non-developmental articulation disorder)

784.69

Other symbolic dysfunction. Excludes developmental learning delays

784.99

Other symptoms involving head and neck

787.20, 787.21, 787.22, 787.23, 787.24, 787.29

Dysphagia code range

V57.3

Care involving speech-language therapy

Note: This diagnosis must be filed in conjunction with one of the diagnosis codes listed above.

[Note: Policy states due to disease, trauma, congenital anomalies, or prior therapeutic intervention - unable to code, non-specific.]

HCPCS

S9128

Speech therapy, in the home, per diem

S9152

Speech therapy, re-evaluation

 

Not Medically Necessary Codes 

Code Number

Description

CPT-4

92521

Evaluation of speech fluency (eg, stuttering, cluttering)

92524

Behavioral and qualitative analysis of voice and resonance

ICD-9 Procedure

 

 

ICD-9 Diagnosis

 

 

HCPCS

 

 

 

 

 

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