BlueCross and BlueShield of Montana Medical Policy/Codes
Speech Therapy
Chapter: Therapies
Current Effective Date: December 27, 2013
Original Effective Date: March 26, 1996
Publish Date: September 27, 2013
Revised Dates: September 1, 2011; September 9, 2013
Description

Speech Therapy (ST) is the treatment of communication impairment and swallowing disorders.

ST services facilitate the development and maintenance of human communication and swallowing through assessment, diagnosis, and rehabilitation. 

Glossary of terms:

Anomia: Word finding and word fluency disorders; inability to name or retrieve the appropriate word upon confrontation.

Aphasia or Dysphasia:  The loss or impairment of language following brain damage.

Aphonia, Dysphonia:  The absence or abnormal production of voice quality, pitch, loudness, resonance and/or duration.  This may be due to disuse or abuse of the vocal mechanism or damage to its anatomical structure (i.e. cancer, vocal nodules, polyps, vocal cord paralysis or hyperfunction).

Apraxia, Dyspraxia:  A disorder resulting from cortical damage, affecting the ability to volitionally control motor programming.  There is no associated weakness.

Aural rehabilitation:  Services and procedures for facilitating adequate receptive and expressive communication in individuals with hearing impairment.

Broca's Aphasia:  Impaired language due to an anterior left hemispheric lesion resulting in nonfluent utterances, restricted vocabulary, articulation errors, and relatively spared auditory comprehension.

Cognitive linguistic impairment, Cognitive‑communicative disorder:  Disabilities encountered in a person's language and conceptual framework that impede his/her functional ability to interact verbally and nonverbally with the environment.  Such impairments are congenital or acquired.    

Dysarthria:  A group of neurogenic speech disorders resulting from damage to the central or peripheral nervous system, causing disturbances in muscular control of the speech mechanisms that affects respiration, phonation, resonance, articulation, and prosody.

Dysfluency, Fluency disorder:  The abnormal flow of verbal expression; interruption of smooth flow of speech.

Dysphagia:  Difficulty in the entire act of deglutition from placement of food in the mouth through the oral and pharyngeal stages of the swallow, until the material enters the esophagus through the cricopharyngeal juncture.

Dysphonia, Aphonia:  The absence or abnormal production of voice quality, pitch, loudness, resonance and/or duration.  This may be due to disuse or abuse of the vocal mechanism or damage to its anatomical structure (i.e. cancer, vocal nodules, polyps, vocal cord paralysis or hyperfunction).

Dyspraxia, Apraxia:  A disorder resulting from cortical damage, affecting the ability to volitionally control motor programming.  There is no associated weakness.

Fluency:  The smooth flow of speech sounds in connected discourse, without interruptions or repetitions.

Hearing impairment:  A hearing disorder whether fluctuating or permanent, which adversely affects an individual's communication performance.  The hard of hearing individual relies upon the auditory channel as the primary sensory avenue for speech and language.

Stutter:  To speak dysfluently; to enunciate certain words with difficulty and with frequent halting and repetition of the initial consonant of a word or syllable.

Wernicke's Aphasia:  Loss of language due to posterior left hemispheric lesion resulting in an inability to comprehend language, and characterized by fluent non-meaningful speech.

Policy

Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.  Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage

Speech therapy (ST) services may be considered eligible for benefit coverage when ST services fulfill all of the following criteria:

  • Prescribed by a licensed physician to restore or improve the function in a member who has impaired physical function of phonation or swallowing, due to disease, trauma, congenital anomalies, or prior therapeutic intervention; AND
  • To achieve condition-specific corrective benefit for a member who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time (usually four to six months); AND
  • Provide specific, effective, and reasonable treatment for the patient’s diagnosis and physical condition; AND
  • Documented plan of care is updated as the patient’s condition changes and is recertified by a physician at least every 30 days, and includes:
    1. Specific long-term and short-term goals; AND
    2. Measurable objectives; AND
    3. Reasonable estimate of when goals will be reached; AND
    4. Specific treatment techniques and/or exercises to be used; and
    5. Frequency and duration of treatment; AND
    6. Clearly document a reduction in the functional deficit over time as compared to normal or average function for members of the same or similar demographic; AND
  • 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; AND
  • Cannot be reasonably taught to and implemented by nonprofessional or lay caregivers; AND
  • 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, e.g., speech pathologist, speech-language pathologist, etc.; AND
  • Do not duplicate services provided by any other therapy, particularly occupational therapy.

NOTE:  In conjunction with delivering speech therapy services, the speech therapist is expected to provide training to the patient, family, and/or caregivers to facilitate their participation in and assumption of the speech therapy, continued improvement and maintenance program. Periodic assessment of improvement and modification of patient- or caregiver-implemented interventions may be appropriate.

Speech Therapy services are considered not medically necessary for any of the following:

  • Speech dysfunction that is self-correcting, such as young children with natural dysfluency or developmental articulation errors not related to a specific medical condition;
  • Maintenance therapy that will preserve the patient’s present level of function and prevent regression of that function, including services intended to maintain function by using routine, repetitive, and reinforced procedures that are neither diagnostic nor therapeutic;
  • Procedures that may be carried out effectively by the patient, family, care giver and/or teacher;
  • Psychoneurotic or psychotic conditions;
  • Developmental delay that is not related to a medical condition, including, but not limited to:
    1. Psychosocial speech delay,
    2. Behavioral problems,
    3. Attention disorders,
    4. Conceptual handicap,
    5. Mental retardation/ intellectual disability,
    6. Reduced cognitive function;
  • Stammering or stuttering that is not related to an underlying medical condition;
  • Therapy with the only goal being instruction of and/or corroboration with other professional personnel in the patient’s speech therapy program or other community resources.

Policy Guidelines

CPT codes 92506, 92507, 92508 are not considered time-based codes; they are intended to be billed one time per session. The initial evaluation is usually completed in 1-3 sessions. 

Rationale

None.

2013 Update

A search of peer reviewed literature through July 2013 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

Procedural Codes: 92506, 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92630, G0153, G0161, S9128
References
  1. BCBSA TEC, Uniform Medical Policy Manual, Allied Health, 12/92, pages 92507.0-92507.7.
  2. AMA, Diagnostic and Therapeutic Technology Assessment, Speech Therapy in Patients with a Prior History of Recurrent Acute or Chronic Otitis Media with Effusion, 1/5/96, pages 1-14.
  3. National Account Consortium Medical Policy Reference Manual, Speech Therapy, 10/31/96, pages 1-5.
  4. Criteria for Determining Disability in Speech-Language Disorders.  Agency for Healthcare Research and Quality.  Evidence Report/Technology Assessment, Number 52. U.S. Department of Health and human Services.  Accessed on 8/19 at www.ahrq.gov
  5. Intensity of aphasia therapy, impact on recovery.  Stroke (2003 Apr) 34(4):987-93.
  6. Language disorders in young children: when is speech therapy recommended?  International Journal of Pediatric Otorhinolaryngology (2003 May) 67(5):525-9.
  7. Speech and language therapy interventions for children with primary speech and language delay or disorder.  Cochrane Database System Review (2003) (3):CD004110.
  8. Speech production in preschoolers with cleft palate.  Cleft Palate-Craniofacial Journal (2005 Jan) 42 (1):7-13.
  9. Speech Therapy.  Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (December 2003) Therapy 8.03.04.
History
October 2010 Revised according to Health Care Reform. Maximum benefit limitations were removed.  
October 2011 Added non-covered code 97530 to policy. This is a non-covered service when billed by Speech Therapy/CPT code 97532 is inclusive to code 92507 when reported on the same day by the same therapy discipline because this is an overlap in services.  
September 2013 Policy formatting and language revised.
BCBSMT Home
®Registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. ®LIVE SMART. LIVE HEALTHY. is a registered mark of BCBSMT, an independent licensee of the Blue Cross and Blue Shield Association, serving the residents and businesses of Montana.
CPT codes, descriptions and material only are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. CPT only © American Medical Association.
Speech Therapy