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Speech Therapy

Section: Therapy
Effective Date: September 01, 2019
Revised Date: August 07, 2019
Last Reviewed: January 22, 2020

Description

Speech therapy is the treatment of communication impairment and swallowing disorders. Speech therapy services involve the use of special techniques to facilitate the development and maintenance of human verbal communication and swallowing through patient assessment, diagnosis, and rehabilitation.

VitalStim® Therapy is a type of neuromuscular electrical stimulation where a small current is passed through external electrodes placed on the neck to stimulate inactive or atrophied swallowing muscles. With repeated therapy, throat muscles are reported to be re-trained and the patient is progresses to an optimum level of swallow function.

Criteria

Speech therapy services may be considered medically necessary when ordered by a physician and performed by a licensed or otherwise certified speech pathologist/therapist. Speech therapy services must be directed to the active treatment of at least ONE of the following conditions: 

  • Disease (e.g., post-cerebrovascular accident, apraxia); or
  • Trauma (e.g., subdural hematoma influencing the speech center); or
  • Congenital malformation anomalies (defects which are the result of imperfect development of an embryo or established during intrauterine life, e.g., craniofacial disorders; [cleft palate and lip]) or congenital hearing impairment); or
  • Previous therapeutic processes (e.g., esophageal training following laryngectomy); or
  • Medical/biological voice dysfunctions associated with vocal cord lesions. 

Voice therapy may be considered medically necessary for ANY of the following conditions (this is not an all-inclusive list): 

  • Closed head trauma; or
  • Laryngeal trauma and trauma related dysphonia's; or
  • Polyps; or
  • Vocal Cord Lesions; or
  • Vocal Cord Paralysis or Paresis; or
  • Vocal Cysts; or
  • Vocal nodules. 

Note: Voice therapy provided prior to surgery is not a covered service. 

Speech therapy services must 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. These services must also provide specific, effective, and reasonable treatment for the patient's diagnosis and physical condition. 

Speech therapy should be provided in accordance with an ongoing, written therapy plan. 

Procedure Codes

92507  92508  92521  92522  92523  92524  96125 
G0153  G0161  S9128  S9152

Habilitative Therapy

Habilitative Speech Therapy, is care provided for conditions which have limited the normal age appropriate motor, sensory or communication development. To be considered habilitative, functional improvement and measurable progress must be made toward achieving functional goals within a predictable period of time toward an individual’s maximum potential.

Functional skills are defined as essential activities of daily life common to all individuals such as dressing, feeding, swallowing, mobility, transfers, fine motor skills, age appropriate activities and communication. Problems such as hearing impairment including deafness, a speech or language impairment, a visual impairment including blindness, serious emotional disturbance, an orthopedic impairment, autism spectrum disorders, traumatic brain injury, deaf-blindness, or multiple disabilities may warrant Habilitative Therapies.

Measurable progress emphasizes accomplishment of functional skills and independence in the contest of the individual’s potential ability as specified within a care plan or treatment goals.

Habilitative/Rehabilitative therapy services must be reported with the 96 or 97 modifiers in conjunction with the appropriate therapy code.

Habilitative therapy is not eligible for payment, unless the member has a habilitative benefit.

Procedure Codes

92507  92508  92521  92522  92523  92524  92630 
92633  G0153  G0161  S9128  96125  S9152

Maintenance Therapy
Speech Therapy services performed repetitively to maintain a level of function is not eligible for payment unless the member has Habilitative Services benefits. A maintenance program consists of activities that preserve the patient's present level of function and prevent regression of that function. These services generally would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness. 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. Maintenance therapy (physical or manipulative therapy performed for maintenance rather than restoration), is not eligible for payment. 

Procedure Codes

S8990

The use of VitalStim for the treatment of dysphagia is considered experimental/investigational and, therefore, non-covered. Scientific evidence of safety and efficacy has not been proven. 

Procedure Codes

92526

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 92507, 92508, 92521, 92522, 92523, 92524, 92630, 92633, 96125, G0153, G0161, S9128 and S9152

F80.0  F80.1  F80.2  F80.4  F80.81  F80.82  F80.89 
F80.9  G93.40  G93.41  G93.49  H93.25  I67.83  I69.023 
I69.123  I69.223  I69.320  I69.323  I69.823  I69.923  J38.00 
J38.01  J38.02  J38.1  J38.2  J38.3  J38.7  K11.7 
Q35.1  Q35.3  Q35.5  Q35.7  Q35.9  Q36.0  Q36.1 
Q36.9  Q37.0  Q37.1  Q37.2  Q37.3  Q37.4  Q37.5 
Q37.8  Q37.9  Q38.1  Q38.5  Q38.8  R06.00  R06.09 
R06.3  R06.83  R06.89  R13.0  R13.10  R13.11  R13.12 
R13.13  R13.14  R13.19  R47.01  R47.02  R47.1  R47.81 
R47.82  R47.89  R48.1  R48.2  R48.8  R48.9  R49.0 
R49.1  R49.21  R49.22  R49.8  R49.9  R68.2  S06.0X0A 
S06.0X1A  S06.0X2A  S06.0X3A  S06.0X4A  S06.0X5A  S06.0X6A  S06.0X7A 
S06.0X9A

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