CMS Pub. 100-02, ch. 15, § 230.3

A. General

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 disorders, which result in communication disabilities and for the

diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presence

of a communication disability. (See Pub. 100-03, chapter 1, §170.3) See section 230.4

of this chapter for benefit policies on speech-language pathologists in private practice

(SLPPP). See Pub. 100-08, Medicare Program Integrity Manual, chapter 10, section

10.2.3.15 for policy on enrollment as an SLPPP.

B. Qualified Speech-Language Pathologist Defined

Reference: 42 CFR 484.115, 42 CFR 410.62(a) and 42 CFR 410.62(a)(3)(iii)

In order to create consistent requirements, in the calendar year (CY) 2005 PFS final rule,

CMS recognized the personnel qualifications applicable to home health agencies (HHAs)

in 42 CFR part 484 as applicable to all outpatient physical therapy, occupational therapy,

and speech-language pathology services. For speech-language pathologists, CMS revised

the basic rule at 42 CFR 410.62(a) to require that the speech-language pathologist must

meet the requirements at 42 CFR § 484.4 as a condition of payment/coverage of

outpatient speech-language pathology services.

The personnel requirements for a speech-language pathologist at 42 CFR 484.4 were

revised in the CY 2015 Home Health Prospective Payment System final rule to parallel

those at section 1861(ll)(a)(4)(A) of the Social Security Act for a speech-language

pathologist, effective January 1, 2015. Later in 2017, as part of the January 2017 HHA

Conditions of Participation (CoPs) final rule, § 484.4 was redesignated as § 484.115 and

42 CFR 410.62(a) was revised to reflect that a speech-language pathologist must meet the

requirements at § 484.115.

Therefore, effective January 1, 2015, a qualified speech-language pathologist is an

individual who has a master's or doctoral degree in speech-language pathology, and who

meets either of the following requirements:

1. Is licensed as a speech-language pathologist by the state in which the individual

furnishes such services; or

2. In the case of an individual who furnishes services in a state which does not

license speech-language pathologists:

a. Has successfully completed 350 clock hours of supervised clinical

practicum (or is in the process of accumulating supervised clinical

experience);

b. Performed not less than 9 months of supervised full-time speech-language

pathology services after obtaining a master's or doctoral degree in speech-language pathology or a related field; and

c. Successfully completed a national examination in speech-language

pathology approved by the Secretary.

For outpatient speech-language pathology services that are provided incident to the

services of physicians/NPPs, the requirement for speech-language pathology licensure

does not apply; all other personnel qualifications do apply. Therefore, qualified

personnel providing speech-language pathology services incident to the services of a

physician/NPP must be a graduate in speech-language pathology with a master’s or

doctoral degree. In a state that does not offer licensure for speech-language pathologists,

the qualified personnel ─ in addition to a master’s or doctoral degree in speech-language

pathology ─ must additionally meet the three above qualifications of 2(a), 2(b), and 2(c).

C. Services of Speech-Language Pathology Support Personnel

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 an aide may help the 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.

D. Application of Medicare Guidelines to Speech-Language Pathology Services

1. Evaluation Services

Speech-language pathology evaluation services are covered if they are reasonable and

necessary and not excluded as routine screening by §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 billable as a separate service.

2. 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.

3. Impairments of the Auditory System

The terms, aural rehabilitation, auditory rehabilitation, auditory processing, lipreading

and speech reading are among the terms used to describe covered services related to

perception and comprehension of sound through the auditory system. See Pub. 100-04,

chapter 12, section 30.3 for billing instructions. 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 aid, other

amplification device or cochlear implant) will not sufficiently meet the patient’s

functional communication needs. Audiologists and speech-language pathologists

both evaluate beneficiaries for disorders of the auditory system using different

skills and techniques, but only speech-language pathologists 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.

4. 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 relates 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.