Automated World Health
Local Coverage Determination (LCD) for Home Health Speech- Language
Pathology (L31533)
Contractor Information
Contractor Name Palmetto GBA
Contractor Number 11004
Contractor Type HHH MAC
LCD Information
Document Information
LCD ID Number L31533
LCD Title Home Health Speech-Language Pathology
Contractor's Determination Number J11HH-11-004-L
AMA CPT/ADA CDT Copyright Statement
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Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.
Primary Geographic Jurisdiction Alabama Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi North Carolina New Mexico Ohio Oklahoma South Carolina Tennessee Texas
Oversight Region Region IV
Original Determination Effective Date
For services performed on or after 01/24/2011 Original Determination Ending Date
Revision Effective Date
For services performed on or after 01/01/2013
Revision Ending Date
CMS National Coverage Policy
Title XVIII of the Social Security Act, §1862 (a)(1)(A). allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Title XVIII of the Social Security Act, §1862(a)(7).This section excludes routine physical examinations
CMS Manual System, Pub. 100-01, Medicare General Information, Eligibility, Entitlement Manual, Chapter 1,
§10.2
CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 7, §§30.1.1, 30.2.1, 30.2.2, 30.3,
30.4, 40.1.2.1, 40.2.1, 40.2.3, and 50.1
CMS Manual System, Pub 100-03, Medicare National Coverage Determination, Chapter 1, Part 1, §§50.1, 50.2, 50.3, and 50.4
CMS Manual System, Pub 100-03, Medicare National Coverage Determination, Chapter 1, Part 3, §§170.2 and 170.3
CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Ch 5, §20.2
CMS Manual System, Pub.100-08, Medicare Program Integrity Manual, Chapter 13, §§13.1.1-13.13.14
Indications and Limitations of Coverage and/or Medical Necessity
Speech-language pathology services are part of a constellation of rehabilitative services designed to improve or restore cognitive functioning, communication skills and/or swallowing skills following congenital or acquired disease or injury. Speech-language pathologists 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. The specific interventions most commonly utilized are tasks/exercises to improve, maintain, train or retrain cognitive/memory skills, swallowing skills and overall communication skills; either verbal or non-verbal so the individual can communicate and function as effectively as possible with daily activities.
1. Speech/hearing evaluation (CPT 92506)
The identification, assessment diagnoses, and evaluation for disorders of:
a. Speech, articulation, fluency, and voice (including respiration, phonation, and resonance)
b. Language skills (involving the parameters of phonology, morphology, syntax, semantics, and pragmatics, and including disorders of receptive and expressive communication in oral, written, graphic, and manual modalities)
c. Cognitive aspects of communication (including communication disability and other functional disabilities associated with cognitive impairment).
*Note: The condition for which the speech-language pathologist is seeing patient must be expected to improve.
2. Speech/hearing treatment (CPT 92507)
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. Regarding speech generating devices, use CPT 92607 for selection and prescription; use CPT 92609 for adaptation and training;
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.
3. Speech/Aural rehabilitation following cochlear ear implant (CPT codes 92626, 92627, 92630 and 92633)
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.
4. Clinical evaluation of swallowing function (CPT 92610)
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 two phases:
a. The pre-swallowing assessment/preparatory examination with no swallow, and
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 and instrumental examination, in the speech-language pathologist’s 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 and 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.
5. Oral function therapy (CPT 92526)
This involves the treatment for impairments/functional limitations of mastication, the preparatory, oral, and pharyngeal phases of swallowing. The speech-language pathologist may make appropriate recommendations (re: diet and compensatory techniques and instruct in direct/indirect therapies) to facilitate oral motor control for feeding.
6. Evaluation of patient for prescription of speech generating devices (CPT 92607 & 92608)
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 a speech-generating device or aid.
7. Patient adaptation and training for use of speech generating devices (CPT 92609)
Includes development of operational competence in using a speech generating device 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.
8. Re-evaluation of patient using speech generation devices: (CPT 92607/92609)
Re-evaluation of patient using speech generating devices or aids to supplement oral speech, assess need for continued use or identify need for changes in objectives.
9. Evaluation of patient for prescription of voice prosthetic (CPT 92506)
Patient is seen for a recommendation of a voice prosthetic. Patient’s ability to perform mechanics necessary to provide voice, care and cleaning of the unit are evaluated, as well as patient’s preference for the unit. (e.g., of voice prosthetics are tracheoesophageal valves, electrolarynges, speaking valves, and voice amplifiers).
10. Modification or training in use of voice prosthetic (CPT 92507)
Modifications in voice prosthetic to supplement oral speech would be appropriate and should be carried out by a speech-language pathologist. (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.
11. Assessment of aphasia (CPT 96105)
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.
12. Developmental testing; limited (CPT 96110)
This includes screening/observations of cognitive abilities, gross and fine motor abilities and communication abilities necessary for performing daily activities, with interpretation and report.
13. Developmental testing; extended (CPT 96111)
This includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments; with interpretation and report.
14. Neurobehavioral status exam (CPT 96116)
Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g. acquired knowledge, attention, memory, visual spatial abilities, language functions, planning) with interpretation and report
15. Standardized cognitive performance testing (CPT 96125)
Evaluate abilities of executive (cognitive) function including: assessment of learning abilities, memory and working memory, abstract thought, language, and attention.
16. Therapeutic exercises (CPT 97110)
Describes exercises used to strengthen muscles (e.g., jaw, tongue, facial)
17. Therapeutic activities (CPT 97530) Printed on 1/26/2013. Page 4 of 11
Use of dynamic activities to improve functional performance
18. Cognitive skills development (CPT 97532)
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.
19. Sensory Integrative Techniques (CPT 97533)
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.
20. Self-care/home management training (CPT 97535)
Compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment.
Coding Information
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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
032x Home Health - Inpatient (plan of treatment under Part B only)
033x Home Health - Outpatient (plan of treatment under Part A, including DME under Part A)
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 policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
0440 Speech Therapy - Language Pathology - General Classification 0441 Speech Therapy - Language Pathology - Visit
0444 Speech Therapy - Language Pathology - Evaluation or Reevaluation
CPT/HCPCS Codes
Note: CPT/HCPCS code G0153 must be used by Home Health agencies billing a 32x or 33x bill types. The G0153 code is used to report the 15-minute increments, all other CPT/HCPCS codes listed in this policy are for informational and descriptive use only.
92506 Speech/hearing evaluation
92507 Speech/hearing therapy Printed on 1/26/2013. Page 5 of 11
92526 Oral function therapy 92607 Ex for speech device rx 1hr
92608 Ex for speech device rx addl 92609 Use of speech device service 92610 Evaluate swallowing function 92626 Eval aud rehab status
92627 Eval aud status rehab add-on 92630 Aud rehab pre-ling hear loss 92633 Aud rehab postling hear loss 96105 Assessment of aphasia
96110 Developmental screen 96111 Developmental test extend
96116 Neurobehavioral status exam 96125 Cognitive test by hc pro 97110 Therapeutic exercises
97530 Therapeutic activities
97532 Cognitive skills development 97533 Sensory integration
97535 Self care mngment training
ICD-9 Codes that Support Medical Necessity
294.11 DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE
294.21 DEMENTIA, UNSPECIFIED, WITH BEHAVIORAL DISTURBANCE
307.0 ADULT ONSET FLUENCY DISORDER
307.23 TOURETTE’S DISORDER
307.50 EATING DISORDER UNSPECIFIED
307.59 OTHER DISORDERS OF EATING
307.9 OTHER AND UNSPECIFIED SPECIAL SYMPTOMS OR SYNDROMES NOT ELSEWHERE CLASSIFIED
310.1 PERSONALITY CHANGE DUE TO CONDITIONS CLASSIFIED ELSEWHERE
315.00 - 315.09 DEVELOPMENTAL READING DISORDER UNSPECIFIED - OTHER SPECIFIC DEVELOPMENTAL READING DISORDER
315.31 - 315.32 EXPRESSIVE LANGUAGE DISORDER - MIXED RECEPTIVE-EXPRESSIVE LANGUAGE DISORDER
315.34 SPEECH AND LANGUAGE DEVELOPMENTAL DELAY DUE TO HEARING LOSS
315.35 CHILDHOOD ONSET FLUENCY DISORDER
315.4 - 315.8 DEVELOPMENTAL COORDINATION DISORDER - OTHER SPECIFIED DELAYS IN DEVELOPMENT
331.0 ALZHEIMER'S DISEASE
331.6 CORTICOBASAL DEGENERATION
341.0 - 341.1 NEUROMYELITIS OPTICA - SCHILDER'S DISEASE
341.8 - 341.9 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED
358.30 LAMBERT-EATON SYNDROME, UNSPECIFIED
358.31 LAMBERT-EATON SYNDROME IN NEOPLASTIC DISEASE
358.39 LAMBERT-EATON SYNDROME IN OTHER DISEASES CLASSIFIED ELSEWHERE
359.21 MYOTONIC MUSCULAR DYSTROPHY
359.22 MYOTONIA CONGENITAL
359.23 MYOTONIC CHONDRODYSTROPHY
359.24 DRUG INDUCED MYOTONIA
359.29 OTHER SPECIFIED MYOTONIC DISORDER
359.3 PERIODIC PARALYSIS
359.4 TOXIC MYOPATHY
388.40 ABNORMAL AUDITORY PERCEPTION UNSPECIFIED
388.41 DIPLACUSIS
388.43 IMPAIRMENT OF AUDITORY DISCRIMINATION
388.45 ACQUIRED AUDITORY PROCESSING DISORDER
389.00 - 389.04 CONDUCTIVE HEARING LOSS UNSPECIFIED - CONDUCTIVE HEARING LOSS INNER EAR
389.05 - 389.06 CONDUCTIVE HEARING LOSS, UNILATERAL - CONDUCTIVE HEARING LOSS, BILATERAL
389.08 CONDUCTIVE HEARING LOSS OF COMBINED TYPES
389.10 - 389.12 SENSORINEURAL HEARING LOSS UNSPECIFIED - NEURAL HEARING LOSS, BILATERAL
389.13 NEURAL HEARING LOSS, UNILATERAL 389.14 -
389.16 CENTRAL HEARING LOSS - SENSORINEURAL HEARING LOSS, ASYMMETRICAL
389.17 SENSORY HEARING LOSS, UNILATERAL
389.18 SENSORINEURAL HEARING LOSS, BILATERAL
389.20 MIXED HEARING LOSS, UNSPECIFIED
389.21 MIXED HEARING LOSS, UNILATERAL
389.22 MIXED HEARING LOSS, BILATERAL
389.7 DEAF, NONSPEAKING, NOT ELSEWHERE CLASSIFIABLE
438.10 SPEECH AND LANGUAGE DEFICIT UNSPECIFIED
438.11 APHASIA
438.12 DYSPHASIA
438.13 LATE EFFECTS OF CEREBROVASCULAR DISEASE, DYSARTHRIA
438.14 LATE EFFECTS OF CEREBROVASCULAR DISEASE, FLUENCY DISORDER
438.19 OTHER SPEECH AND LANGUAGE DEFICITS
438.81 APRAXIA CEREBROVASCULAR DISEASE
438.82 DYSPHAGIA CEREBROVASCULAR DISEASE
438.83 FACIAL WEAKNESS
478.30 - 478.34 UNSPECIFIED PARALYSIS OF VOCAL CORDS - COMPLETE BILATERAL PARALYSIS OF VOCAL CORDS
478.5 OTHER DISEASES OF VOCAL CORDS
524.20 - 524.29 UNSPECIFIED ANOMALY OF DENTAL ARCH RELATIONSHIP - OTHER ANOMALIES OF DENTAL ARCH RELATIONSHIP
524.50 DENTOFACIAL FUNCTIONAL ABNORMALITY, UNSPECIFIED
529.8 OTHER SPECIFIED CONDITIONS OF THE TONGUE
750.0 TONGUE TIE
750.10 - 750.19 CONGENITAL ANOMALY OF TONGUE UNSPECIFIED - OTHER CONGENITAL ANOMALIES OF TONGUE
780.99 OTHER GENERAL SYMPTOMS
781.8 NEUROLOGIC NEGLECT SYNDROME
783.3 FEEDING DIFFICULTIES AND MISMANAGEMENT
783.42 DELAYED MILESTONES
784.3 APHASIA
784.40 VOICE AND RESONANCE DISORDER, UNSPECIFIED
784.41 APHONIA
784.42 DYSPHONIA
784.43 HYPERNASALITY
784.44 HYPONASALITY
784.49 OTHER VOICE AND RESONANCE DISORDERS
784.51 DYSARTHRIA
784.52 FLUENCY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
784.59 OTHER SPEECH DISTURBANCE
784.60 - 784.69 SYMBOLIC DYSFUNCTION UNSPECIFIED - OTHER SYMBOLIC DYSFUNCTION
784.99 OTHER SYMPTOMS INVOLVING HEAD AND NECK
786.1 STRIDOR
786.2 COUGH
787.20 DYSPHAGIA, UNSPECIFIED
787.21 DYSPHAGIA, ORAL PHASE
787.22 DYSPHAGIA, OROPHARYNGEAL PHASE
787.23 DYSPHAGIA, PHARYNGEAL PHASE
787.24 DYSPHAGIA, PHARYNGOESOPHAGEAL PHASE
787.29 OTHER DYSPHAGIA
799.52 COGNITIVE COMMUNICATION DEFICIT
V40.1 MENTAL AND BEHAVIORAL PROBLEMS WITH COMMUNICATION (INCLUDING SPEECH) V41.2 PROBLEMS WITH HEARING
V41.4 PROBLEMS WITH VOICE PRODUCTION
V41.6 PROBLEMS WITH SWALLOWING AND MASTICATION
V43.81 LARYNX REPLACEMENT STATUS
V48.2 - V48.7 MECHANICAL AND MOTOR PROBLEMS WITH HEAD - DISFIGUREMENTS OF NECK AND TRUNK
V52.8 FITTING AND ADJUSTMENT OF OTHER SPECIFIED PROSTHETIC DEVICE
V55.0 ATTENTION TO TRACHEOSTOMY
Diagnoses that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity
Any ICD-9 CM codes not listed in ICD-9-CM Codes That Support Medical Necessity section of this policy may be subject to medical review.
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
General Information
Documentations Requirements
1. Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to the A/B MAC upon request.
2. The plan of treatment written by the patient’s physician after any needed consultation with the qualified speech-language pathologist and signed by the physician. This must be in the patient’s medical record and made available to the A/B MAC upon request.
3. When documenting family member/caregiver or communication partner training and education, the documentation should include the person being trained and the effectiveness of the training and education. The training and education should be an adjunct to active therapy with the patient.
4. OASIS data should support the medical necessity of the services documented in the medical records. For therapy services the OASIS MO2200 should be filled out completely and filed with the State Repository. An updated and completed OASIS for the billing period should be on file with the State Repository and in the patient’s medical records to be made available to the A/B MAC upon request.
Evaluation/Reevaluations
The physician and/or the speech-language pathology’s evaluation/re-evaluation assess the area for which speech- language therapy is being planned. It must be completed prior to beginning therapy. Evaluations must contain
the following information:
1. Reason for referral
2. Diagnosis/condition being treated
3. Past level of function (be specific)
4. Evaluations must contain physical and cognitive baseline data necessary for assessing rehabilitation potential and measuring progress.
5. Current level of function
6. Treatment modalities selected for treating current illness or injury
7. Limitations which may influence the length of treatment
8. Short and long term goals stated in objective measurable terms, and their expected date of accomplishment
9. Frequency and duration of therapy
10. Re-assessments must be performed at least every 30 days by a qualified speech-language pathologist. The 30 day clock begins with the first therapy’s visit/assessment/measurement/documentation (of the speech- language pathologist).
Plan of Treatment
Services are to be furnished according to a written plan of treatment determined by the physician after any needed consultations with the qualified speech-language pathologist and signed by the physician after an appropriate assessment (evaluation) of the condition (illness or injury) is completed. In the absence of a verbal order, the written plan of treatment must be completed before active therapy begins. The plan of treatment, it must be signed by the referring or attending physician prior to billing the service to Medicare. The written plan of treatment established by a physician may not be altered by a speech-language pathologist. *Electronic signatures are acceptable if the proper documentation is submitted to the A/B MAC. However stamped dates are not
allowed.
1. The written plan of treatment must contain the following elements:
a. Diagnosis being treated and the specific problems identified that are to be addressed
b. Specific treatments/interventions being used for each specific problem to attain the stated goals
c. Specific functional goals for the treatments/interventions in measurable terms
d. Amount, frequency, and duration of each treatment/intervention
e. Rehabilitation potential - therapists/physician’s expectation of the patient’s ability to meet the goals at initiation of treatment
Treatment Notes/Progress Notes
1. A treatment note should be written for each visit. It should contain the objective measurable status of the patient, a description of the services performed, and the patient’s response, in objective measurable terms, to the services. Weekly progress notes should describe progress toward the treatment goals.
2. The treatment note should document any treatment variations with the associated rationale.
3. The treatment notes should be written using objective measurements and functional accomplishments. Use statements which demonstrate the patient’s response to the therapy such as:
a. “Able to answer questions with 75% accuracy”
b. “Name common items with 80% accuracy”
c. “Able to sustain phonation 10 seconds during vowel production”
d. “Oral intake trials without signs and symptoms of aspiration”
4. Avoid terms that are not quantified, such as:
a. “Doing well”
b. “Improving”
c. “Less pain”
d. “Tolerated treatment well”
Certification/Recertification
1. The certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient. The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care.
2. Content of the Physician’s Certification—No payment may be made for the Home Health speech-language pathology services unless the physician certifies that:
a. A plan for furnishing such services is or was established by the physician after any needed consultation with the qualified speech-language pathologist and reviewed by the physician every certification/re-certification period.
b. The services are or were furnished while the patient was under a written plan of care by a physician.
c. The services are or were required by the patient.
3. Certifications and re-certifications by the physician, must be on file and available to the A/B MAC upon request.
4. Certifications are required upon initiation of therapy and with every certification/re-certification period thereafter for Home Health speech-language pathology services.
5. The referring/attending physician establishes or reviews the plan of treatment and makes the necessary certifications. The referring/attending physician must sign all certifications/re-certifications. Signature means an actual handwritten signature or electronic signature.
6. Documentation should indicate the prognosis for potential restoration of function in a reasonable and generally predictable period of time, or the need to establish a safe and effective maintenance program.
Discharge Planning
1. Should be addressed at the initiation of therapy
2. Documentation must support that the speech-language pathologist discussed discharge planning with the patient/caregiver prior to the final visit.
Appendices N/A
Utilization Guidelines N/A
Sources of Information and Basis for Decision
Nicolosi, L., Harryman, E., and Kersheck, J, (1978). Terminology of Communication Disorders. Maryland: The Williams & Williams Company. Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the A/B MAC, this policy was
developed in cooperation with advisory groups, which includes representatives from the Speech-Language Pathologists and home health providers. Advisory Committee Meeting Date:
Start Date of Comment Period
End Date of Comment Period
Start Date of Notice Period 12/09/2010
Revision History Number Revision #3, 01/01/2013
Revision History Explanation Revision #3, 01/01/2013
Under CPT/HCPCS Codes the following CPT codes have had a descriptor change: 97530, 97532, 97533 and 97535. This Revision becomes effective on 01/01/2013.
Revision #2, 11/23/2012
Under CMS National Coverage Policy the following citations were deleted as they were manualized: CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Transmittal 142, dated April 15, 2011, Change Request 7374 which is now Ch 7, §40.1.2.1 and citation CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Transmittal 2160, dated February 18, 2011, Change Request 7315 is now Ch 5, §20.2. Under Documentation Requirements and Advisory Committee Meeting Notes the word "J11 MAC" was changed to "A/B/MAC." Annual review completed. This revision becomes effective on 11/23/2012
Revision 1, 10/01/2011
Under CMS National Coverage Policy section the following two Change requests were added: CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Transmittal 142, dated April 15, 2011, Change Request 7374, and CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Transmittal 2160, dated February 18, 2011, Change Request 7315. Under ICD-9 Codes That Support Medical Necessity section the following ICD-9 codes were added: 294.21, 331.6, 358.30, 358.31 and 358.39. Under Documentation Requirements section the word Intermediary was changed to J11 MAC. #2 was changed from the speech language pathologist writing the plan of treatment to the physician writing the plan after any needed consultation with the qualified speech-language pathologist and signed by the physician to be consistent with the recent manual changes. #4 the phrase “and filed with the State Repository” was added in relation to the updated and completed OASIS. Under the Evaluation/Reevaluations section #8 the word objective was added and #10 was added about the re-assessments time frame. Under Plan of Treatment added “after any needed consultations with the qualified speech-language pathologist” to the first sentence. Also verbiage was added at the end of the paragraph stating that “stamped dates are not allowed” on Home Health Plan of Treatments. Under Treatment Notes/Progress Notes under #1 added the words “measurable” and “in objective measureable terms”. In #3 the word objective was added. Under Certification/Recertification added #1 about the required face-to-face encounter. Under #2a the phrase “after any needed consultation with the qualified speech-language pathologist” was added to the sentence. This revision becomes effective on 10/01/2011.
01/24/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Palmetto GBA Title 18 RHHI (00380) was removed from this LCD and implemented to Palmetto GBA J11 HH and H MAC (11004). Effective date of this Implementation is January 24, 2011.
11/25/2012 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
97530 descriptor was changed in Group 1 97532 descriptor was changed in Group 1 97533 descriptor was changed in Group 1 97535 descriptor was changed in Group 1
Reason for Change HCPCS/ICD9 Descriptor Change
Related Documents Article(s)
A50420 - Coding Guidelines for Home Health Speech-Language Pathology opens in new window
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All Versions
Updated on 12/10/2012 with effective dates 01/01/2013 - N/A Updated on 11/25/2012 with effective dates 11/23/2012 - 12/31/2012 Updated on 11/12/2012 with effective dates 11/23/2012 - N/A Updated on 11/21/2011 with effective dates 10/01/2011 - 11/22/2012 Updated on 09/23/2011 with effective dates 10/01/2011 - N/A Updated on 11/30/2010 with effective dates 01/24/2011 - N/A