Speech Evaluation codes
As of January 1, 2014, code 92506 (Evaluation of speech, language, voice, communication, and/or auditory processing) has been deleted and replaced with four new, more specific evaluation codes related to the assessment of language, speech sound production, voice and resonance, and fluency disorders.
The old code is 92506–The new assessment codes are:
* 92521 Evaluation of speech fluency (e.g., stuttering, cluttering)
* 92522 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria)
* 92523 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language)
* 92524 Behavioral and qualitative analysis of voice and resonance
The rate structure for these codes for EarlySteps is different from the old rate for 92506 and is explained below, beginning on page 3. In EarlySteps, the 92506 code was used for single-domain assessments, eligibility and exit evaluations and autism screenings. Since the code was discontinued, the replacement codes for evaluations and screenings are:
• 96110 Eligibility and Exit (Outcome Measures) evaluations
• 96111 Autism screenings
The rates for these evaluation and screening codes have not changed. The 96110 and 96111 code changes occur in the Central Finance Office (CFO) Rate and Service Schedule only, since Medicaid does not reimburse for these two codes for EarlySteps.
The following information addresses some of the most commonly asked questions about the new evaluation codes and what changes will occur within EarlySteps.
Instructions for use of new codes in EarlySteps:
1. 92523 used alone will be the most frequently needed/ used code for single domain speech/language assessments. This code includes the evaluation of speech sound production and receptive and expressive language which will be the most appropriate areas of assessment for this age group to identify supports to families provided by the SLP.
2. Decisions related to which assessment to complete, based on the needs of the child and family, will be made by the team, including the SLP, in a team meeting as follows:
o When teams meet and identify the need for a single domain assessment by an SLP, the team meeting notes will summarize the discussion and indicate the need for the assessment.
o The Request for Authorization Form will be used to indicate the CPT code(s) under the “check service” column next to the Single Domain Assessment item for submission to the SPOE.
3. If 92521 or 92524 are added with 92523, the need is identified and summarized in the team meeting notes and requested according to #2 above. The assessment and the report completed by the SLP must include
o an explanation of the needs which prompted these additional components
o the assessment procedures and results for each, as these components may not typically be needed for assessments with the birth to three year old population. For example, a child with a cleft palate may need assessment in the area of resonance (92524). In this scenario, the child may need codes 92523 and 92524. In the report, the SLP will write up the need for 92524 based on the child’s diagnosis and include the assessment procedures and results of the resonance, speech sound and language assessment in the assessment report. The codes will be billed separately and only one report is required.
4. The SLP cannot bill 92522 and 92523 for the same child. Only one is billable in combination with another code such as 92521 or 92524, since both 92522 and 92523 include assessment of speech sound production, when fluency and/or voice are also assessed. EarlySteps does not anticipate that 92522 would ever be appropriately used as a single assessment for this age group. It is more likely that the single code 92523 will be used as the single domain assessment code.
Can the new codes be billed together on the same day or with other existing codes?
The National Correct Coding Initiative (CCI) establishes edits to control specific code pairs that can or cannot be billed on the same day for Medicare and Medicaid services; CCI edits are also followed by many other thirdparty payers. Neither the CPT Handbook nor the National Correct Coding Initiatives (CCI) edits restrict an SLP’s ability to bill the new codes together because there are circumstances when it is appropriate for an individual to be evaluated for multiple disorders on the same day. The exception is the same-day billing of the combination of 92522 and 92523, which is restricted by both the CPT Handbook and CCI edits. Both the CFO system and the Molina system will allow for billing the multiple codes (92521, 92523, 92524, etc) on the same day. All new and updated edits are available on ASHA’s CCI edits webpage.
In cases where multiple evaluations may be appropriate, documentation should clearly reflect a complete and distinct evaluation for each disorder—only one report is required, but all areas for which the child is assessed and codes were billed should be reported. Assessment codes should not be billed for brief assessments that could be considered screenings. Time for identification of other disorders is already built into the value of each code; inappropriate use of multiple assessments on the same day could result in future restrictions through CCI edits.
Why is 92523 a combined speech sound production and language evaluation* What if I perform only a language evaluation?
If two or more procedures are billed together at least 51% of the time, it is standard to develop a bundled CPT code for that set of services. During the code development process, ASHA surveyed practices and clinics and confirmed that a child evaluated for language is also evaluated for speech sound production ability more than 80% of the time. Therefore the combined rate was developed. This code will be the most commonly used code for SLP single domain assessments in EarlySteps. The assessment report will include the results of both assessed areas.
Can I bill 92522 and 92523 together on the same day?
No, you may only bill one or the other. A speech sound production evaluation (CPT 92522) is already included as a part of CPT 92523 (speech sound production evaluation with language evaluation). EarlySteps does not recommend the use of 92522 as a single code for EarlySteps-aged children—92523 is the appropriate code.
How should I bill for a BDI2 eligibility/exit evaluation*
SLPs should bill CPT 96111 (Developmental testing, includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments) for eligibility and exit evaluations. These codes are only billed to the CFO, since Medicaid does not reimburse for eligibility and exit evaluations in EarlySteps.
How should I bill for an autism screening/BISCUIT* SLPs will bill CPT 96110 (developmental screening) for the EarlySteps autism screening. These codes are only billed to the CFO, since Medicaid does not reimburse for autism screenings in EarlySteps. Who should I contact if I have problems billing the new codes?
• Confirm that the authorization was appropriately issued and that you are billing the code(s) authorized. Contact the FSC/SPOE if the authorization needs to be cancelled and re-issued.
• Confirm that you are only billing 92521, 92522, 92523, and/or 92524 to Molina. Medicaid does not reimburse for 96110 or 96111 for EarlySteps and these should not be billed to Molina.
• Contact the EarlySteps regional coordinator if you cannot resolve the billing problem or have a question.
CPT/HCPCS Codes
Group 1 Codes:
92507 Speech/hearing therapy
92508 Speech/hearing therapy
92521 Evaluation of speech fluency
92522 Evaluate speech production
92523 Speech sound lang comprehen
92524 Behavral qualit analys voice
92607 Ex for speech device rx 1hr
92608 Ex for speech device rx addl
92609 Use of speech device service
92626 Eval aud rehab status
92627 Eval aud status rehab add-on
96105 Assessment of aphasia
96110 Developmental screen w/score
96111 Developmental test extend
96125 Cognitive test by hc pro
97532 Cognitive skills development
Coverage Indications, Limitations, and/or Medical Necessity
Indications General Guidelines
Speech Language Pathology (SLP) services may be considered reasonable and necessary when the following criteria are met and supported by the documentation: The conditions of coverage and payment must be met as outlined in the Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 220.1. SLP services are either rehabilitative or maintenance related. The documentation must clearly indicate if skilled therapy services are being provided for rehabilitative purposes or maintenance. Rehabilitative therapy includes services designed to address recovery or improvement in function. Rehabilitative therapy services may be covered if the documentation indicates that the skills of the therapist are needed and are provided and if the documentation indicates by objective measurements that improvements are being made, or a decrease in severity is present, or rationalization for an optimistic outlook is present to justify continued treatment. For coverage requirements for maintenance related services, see number 7 below.
SLP services are covered, provided such services are of a level of complexity and sophistication, or the patient’s condition is such that the services can be safely and effectively performed only by a licensed qualified Speech Language Pathologist. Services normally considered to be a routine part of nursing care are not covered.
For rehabilitative therapy, the goal for a patient is to return to the highest level of function realistically attainable and within the context of the disability. The skills of the therapist may not necessarily be required to attain this goal but may be required initially to ensure safety, proper modality performance, etc. then transferring their care to a caregiver and home program.
Covered SLP services must relate directly and specifically to an active written treatment plan and must be reasonable and necessary to the treatment of the individual’s illness or injury. The plan of treatment should address specific therapeutic goals for which modalities and procedures are outlined in terms of type, frequency and duration. The plan of care must be certified/approved by the physician/NPP.
In order for the plan of care to be covered, it must address a condition for which SLP is an accepted method of treatment, as defined by standards of medical practice. For rehabilitative therapy, there must be an expectation that the condition will improve significantly in a reasonable and generally predictable period of time based on the physician’s assessment of the patient’s rehabilitation potential, after any needed consultation with the qualified therapist. The documentation must clearly support this expectation. For maintenance therapy, the documentation must clearly indicate that:
the skills of the therapist must be necessary to establish a safe and effective maintenance program in connection with a specific disease state, or the services required to maintain the patient’s current function or to prevent or to slow further deterioration are of such complexity and sophistication that the skills of a therapist are required, or the particular patient’s special medical complications require the skills of a therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration.
The therapist must document the patient’s functional limitations in terms that are objective and measurable. The therapist must document the therapeutic short and long term goals in terms that are objective and measurable. SLP services are not covered when the documentation fails to support that the functional ability or medical condition was impaired to the degree that it required the skills of a therapist.
Rehabilitative SLP services are not covered when the documentation indicates the patient has not reached the therapy goals and is not making significant improvement or progress, and/or is unable to participate and/or benefit from skilled intervention or refused to participate. Establishing or designing a maintenance program or instructing the patient or appropriate caregiver in a maintenance program is not covered if the specialized skill, knowledge and judgment of a therapist are not required. Performance of a maintenance program by the therapist is not covered if the maintenance procedures do not require the skills of a therapist or the patient’s medical complications are not complex to require the skills of a therapist to perform the maintenance procedures. The skills of a therapist are not generally required to maintain function. In addition, establishing, designing or performing a maintenance program is not covered if the patient would not benefit from it or refuses to participate.
Rehabilitative SLP services are not covered when the documentation indicates that a patient has attained the therapy goals or has reached the point where no further significant practical improvement can be expected.
The design of a maintenance regimen/home speech program required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease may be considered reasonable and necessary if the skills of the therapist are required. Limited services may be considered reasonable and necessary to establish and assist the patient and/or caregiver with the implementation of a rehabilitation maintenance program/home program. No more than 2-4 visits for completion of the maintenance program and instruction of the patient and supportive personnel or family are considered medically necessary without significant documentation. Documentation must indicate that the maintenance program has been designed for the patient’s level of function and instructions to the patient and supportive personnel have been completed. The initiation of a maintenance program should occur early in a course of therapy.
SLP services are not covered to treat Skilled Nursing Facility patients whose care can safely and effectively be rendered by the Skilled Nursing Facility’s trained professional staff. .
SLP therapy is not covered when a patient suffers a temporary loss or reduction of function and could reasonably be expected to improve spontaneously without the services of the Speech Language Pathologist. For example, the patient with a TIA with speech deficits that are resolving.
SLP services provided to identify patients who might need or benefit from SLP services (i.e. screening) intervention are not covered.
SLP services visits would not be routinely covered on a daily basis through discharge. Normally, visit frequency would decrease as the patient’s condition improves.
SLP services which are duplicative of other concurrent rehabilitation services are not covered.
Services which are related solely to specific employment opportunities (i.e., on-the-job training, work skills, or work settings) are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are not covered.
The educational component of treatment is included in the service described by the specific CPT code; therefore there is no separate coverage for education.
Documentation of services is part of the coverage of the respective CPT. Therefore there is no separate coverage for time spent on documentation.
The service must be considered acceptable under state standards of practice to be a specific and effective treatment for the beneficiary’s condition.
The amount, frequency and duration of the services must be reasonable under accepted standards of practice.
If a separate maintenance program is required, the documentation must demonstrate the need for development of a distinct and separate maintenance program which could only be completed safely by a Speech Language Pathologist.
EVALUATIONS/ASSESSMENTS
CPT 92522 – Evaluation of Speech Sound Production and CPT 92523 – Evaluation of Speech Sound Production with Evaluation of Language Comprehension and Expression
The Speech Language Pathologist employs a variety of formal and informal speech and language assessment tests to ascertain the type, causal factor(s), and severity of the speech and language disorders. Re-evaluation of patients for whom speech and language services were previously contraindicated would be covered only if the patient exhibited a significant change in medical condition. However, monthly re-evaluations for a patient undergoing a rehabilitative SLP program, are to be considered a part of the treatment session and could not be covered as a separate evaluation for billing purposes.
The evaluation/re-evaluation should demonstrate that an actual hands-on assessment occurred to support coverage. Screening assessments are noncovered and should not be billed.
Additional Documentation Requirements
History and the onset or exacerbation date of the current disorder. The history in conjunction with the current symptoms must establish support for additional treatment.
Prior level of functioning; as well as current baseline abilities, to establish the basis for the therapeutic interventions.
The plan, goals (realistic, long-term, functional, measurable, communication goals) duration of therapy, frequency of therapy, and definition of the type of service – rehabilitative or maintenance.
Diagnostic and assessment services to ascertain the type, causal factor(s) and severity of speech, language and/or cognitive communication disorders, should be identified during the evaluation.
CPT 92607 – Evaluation For Prescription For Speech-Generating Augmentative And Alternative Communication Device, Face-To-Face With The Patient; First Hour
CPT 92608 – Evaluation For Prescription For Speech-Generating Augmentative And Alternative Communication Device, Face-To-Face With The Patient; Each Additional 30 Minutes (List Separately In Addition To Code For Primary Procedure)
The Speech-Generating Device (SGD) evaluation is conducted to determine the appropriateness and selection of devices that synthesize or digitize speech and enhance communication of patients with expressive and/or receptive communication disorders.
The SGD evaluation considers the needs, abilities, and preferences of the patient and of the patient’s communication partner(s).
This SGD evaluation is usually the result of a physician referral or by the failure of a speech and language evaluation (CPT 92522/92523). This assessment is covered once.
Additional Documentation Requirements
Basis for evaluation: referral or failed speech language evaluation.
Communication disorder: diagnosis, onset, duration, severity, anticipated course (i.e. progressive, stable, improving).
The cognitive and communication abilities of the individual based on the formal evaluation.
Previous level of communication; use of other AAC devices.
Results of device trials.
Rationale for devices and/or accessories related to daily functional needs.
Measurable short and long term goals relating to functional communication need.
Timeframe for completing these goals.
Participation of communication partner/caregiver when applicable.
Time spent performing each CPT code.
CPT 96105 – Assessment Of Aphasia (Includes Assessment Of Expressive And Receptive Speech And Language Function, Language Comprehension, Speech Production Ability, Reading, Spelling, Writing, Eg, By Boston Diagnostic Aphasia Examination) With Interpretation And Report, Per Hour
A comprehensive aphasia assessment that is covered once.
Other tests in this category include the Western Aphasia Battery, The Minnesota Differential Diagnosis Examination of Aphasia, etc.
Conducted when more detailed linguistic information is needed to plan the treatment program of patients with moderate to mild aphasia.
Documentation should reflect the comprehensive nature of the assessment.
Regular progress reports, at least every ten treatment visits, conducted to determine or document progress, e.g., Western Aphasia Battery, for a patient undergoing a rehabilitative SLP program, are to be considered a part of the treatment session and could not be covered as a separate evaluation for billing purposes.
For patients with severe aphasia, comprehensive assessments such as those listed above would not be performed routinely without documentation explaining the need.
THERAPEUTIC SERVICES
CPT 92507 – Treatment Of Speech, Language, Voice, Communication, And/ Or Auditory Processing Disorder; Individual
Rehabilitative therapeutic services must improve the beneficiary’s functional abilities. Medicare will cover those skilled procedures that are reasonable and necessary for rehabilitative purposes or, if the skills of the therapist are required, to establish and instruct in a maintenance program. Those services that are unskilled are not covered by Medicare.
Skilled procedures include:
Design of a treatment program relevant to the beneficiary’s disorder. Continued assessment and analysis during the implementation of the services is expected at regular intervals.
Establishment of compensatory skills for communication (e.g., air injection techniques or word finding strategies).
Establishment of a hierarchy of speech-language cognitive communication tasks and cuing that directs a beneficiary toward communication goals.
Analysis related to actual progress toward goals.
Patient and family training to augment rehabilitative treatment or to establish a maintenance program which requires the skills of a therapist. Education of staff and family must begin after the initial evaluation and after the design of a maintenance program. Additional modalities for education of staff in maintenance or rehabilitative programs will not be considered a covered service.
Documentation must be present to support the ability of the beneficiary to follow, learn and retain instruction for rehabilitative therapy. Absence of this documentation will result in a denial of services. For establishment and instruction in a maintenance program which requires the skills of a therapist, there must be documentation of the training which is provided to the patient and/or caregiver. The unavailability of a caregiver to provide a non-skilled service, notwithstanding the importance of the service to the patient, does not make the performance of the non-skilled maintenance program a skilled service when the therapist furnishes the service.
Medicare does not recognize the SLP aide or anyone other than the licensed Speech Language Pathologist for re-imbursement purposes.
The following are examples of common medical disorders and resulting communication deficits which may necessitate active skilled therapy: This list should not be considered 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.
Laryngeal carcinoma requiring laryngectomy, resulting in aphonia.
Unskilled Procedures include:
Nondiagnostic/nontherapeutic routine, repetitive and reinforced procedures (e.g., the practicing of work drills without skilled feedback).
Procedures which are repetitive and/or reinforcing of previously learned material which the patient or family is instructed to repeat.
Procedures which may be effectively carried out with the patient by any nonprofessional (e.g., family member, restorative nursing aide) after instruction and training is completed.
Provision of practice for use of augmentative or alternative assessment communication systems.
Supervision of the patient practicing the use of speech generating devices and non-speech generating devices.
Additional Documentation Requirements
Basic hearing evaluation; and audiogram.
Identification of type and extent of hearing loss.
Alertness of the beneficiary.
Adequate cognitive and memory skills.
Visual acuity (with glasses) of the beneficiary, to determine ability to participate with the therapy.
Motivation to undergo therapy in order to improve understanding of speech.
CPT 92508 – Treatment Of Speech, Language, Voice, Communication, And/Or Auditory Processing Disorder (Includes Aural Rehabilitation); Group, Two Or More Individuals
Group therapy may be covered when the following criteria are met:
Group therapy services are rendered under an individualized plan of treatment, and are integral to the achievement of the patient’s individualized goals.
The skills of a Speech Language Pathologist are required to safely and/or effectively carry out the group services.
The group consists of four or fewer group members.
The group therapy satisfies all of the “reasonable and necessary criteria” listed under Indications and Limitations of Coverage.
Group therapy sessions in social organizations such as the Stroke Club or Lost Cord Club are not covered.
Additional Documentation Requirements
Documentation of the specific skilled treatments used in the group and how they relate to the Plan of Care.
Documentation of the number of persons in the group.
CPT 92609 – Therapeutic Services For The Use Of Speech-Generating Device, Including Programming And Modification
These services should reflect a program instructing a patient how to use a device and acquire the necessary skills for functional communication with the device.
Practice use of the device is not considered a skilled service and therefore is noncovered.
When the service is provided on the same date of service as CPT 92508, the documentation should reflect separate and distinct services.
CPT 92626 – Evaluation Of Auditory Rehabilitation Status; First Hour
CPT 92627 – Evaluation Of Auditory Rehabilitation Status; Each Additional 15 Minutes (List Separately In Addition To Code For Primary Procedure)
Aural rehabilitation may be covered and medically necessary when it has been determined by a speech-language pathologist in collaboration with an audiologist that the beneficiary’s current amplification options (hearing aid, other amplification device or cochlear implant) will not sufficiently meet the patient’s functional communication needs.
Assessment for the need for aural rehabilitation may be done by a speech language pathologist and includes 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.
Aural rehabilitation consists of 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.
CPT 97532 – Development Of Cognitive Skills To Improve Attention, Memory, Problem Solving, (Includes Compensatory Training), Direct (One-On-One) Patient Contact, Each 15 Minutes
Development of cognitive skills, as described by code 97532, seeks to improve attention, memory and problem solving, and includes compensatory training, which refers to training provided to make up for a deficiency or loss of cognitive skills. This is often indicated for adults with diagnoses of psychiatric disorders, brain injuries and cerebral vascular accidents (CVAs). Cognitive skill training may allow individuals with these types of impairments to live independently, return to work, and function safely in their environments. Cognitive impairments are broken down into three categories: Attentional Impairments, Short Term Memory Impairments and Problem Solving Impairments. As the definition of the goal is “to improve”, this service would not be expected to be used with maintenance therapy.
Plan of treatment should document specific short and long term measurable goals of treatment and that significant gains are reasonable and expected.
Documentation should indicate measurable progress toward goals and that the beneficiary is able to participate if compensatory training is part of the treatment.
Documentation must be present to support the ability of the beneficiary to follow, learn and retain instruction. Absence of this documentation will result in a denial of services.
Throughout the course of their disease, patients with cognitive disorders may benefit from speech-language pathology therapies. However, the use of diagnosis codes for cognitive deficits alone may not adequately define the extent of a beneficiary’s cognitive impairment and its relevance to a functional impairment. Documentation must support that these therapies are reasonable and necessary when reviewed in the context of the beneficiary’s overall functional impairment. Services for stable chronic illness are not expected to be reasonable and necessary.
CENTRAL NERVOUS SYSTEM ASSESSMENT/TESTS
CPT 96110 – Developmental Testing; Limited (Eg, Developmental Screening Test II, Early Language Milestone Screen), With Interpretation And Report
CPT 96111 – Developmental Testing; Extended (Includes Assessment Of Motor, Language, Social, Adaptive And/Or Cognitive Functioning By Standardized Developmental Instruments) With Interpretation And Report
CPT 96125 – Standard cognitive performance testing (eg., Ross Informational Processing Assessment) per hour of a qualified health care professional’s time, both face-to-face with the patient and time interpreting test results and preparing the report.
These tests evaluate different aspects of neurocognitive ability in patients who have compromised functioning due to acute neurological events such as traumatic brain injury or cerebrovascular accident (CVA). The assessment includes memory, reasoning, sensory processing, visual perceptual status, orientation, right hemisphere processing for temporal and spatial organization, social pragmatics, and elements of decision-making and executive function.
A separate interpretation and report should be readily located in the medical record.
This assessment is considered specialized and not routine.
Limitations
Nondiagnostic/nontherapeutic routine, repetitive and reinforced procedures (e.g., the practicing of word drills without skilled feedback).
Procedures which are repetitive and/or that reinforce previously learned material which the beneficiary, staff or family may be instructed to repeat.
Procedures which may be effectively carried out with the beneficiary by any nonprofessional (family or restorative aide) after instruction is completed.
Provision of practice for use of augmentative or alternative assessment communication systems.
Contradictory documentation (as to the mental status and learning ability of the beneficiary) between nursing and therapists of any discipline will be subject to denial.
Statements such as “mildly impaired to moderately impaired” or “fair plus to good minus” do not offer sufficient objective and measurable information to support progress and may result in denial of services.
Memory aids such as memory books, memory boards, or communication books which by description mimic memory books will not be covered.
Metronome therapy
The following disorders are typically noncovered for the geriatric beneficiary:
Fluency disorder, dysprosody, stuttering and cluttering (except neurogenic stuttering caused by acquired brain damage)
Myofunctional Disorders (e.g., tongue thrust)
SLP services interventions for communication difficulties demonstrated by beneficiaries with primary language other than English will not be covered for SLP services interventions to instruct the beneficiary in English phrases. This type of intervention is not considered reasonable and necessary and is not reimbursable. However, when the primary language of the beneficiary is other than English, SLP services interventions in the patient’s primary language will be covered in the context of this policy.
Policy: This CR updates the therapy code list with one “sometimes therapy” code, four “always therapy” codes, and deletes two current codes for CY 2014 as follows:Sometimes therapy codes:
Add: 97610 – Low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day Delete: 0183T
Note: 97610 replaces current code 0183T effective 1/1/2014 Always therapy codes:
Add: 92521 – Evaluation of speech fluency (eg, stuttering, cluttering)
Add: 92522 – Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)
Add: 92523 – with evaluation of language comprehension and expression (eg, receptive and expressive language
Add: 92524 – Behavioral and qualitative analysis of voice and resonance Delete: 92506
Exceptions for Evaluation Services
Evaluation. The CMS will except therapy evaluations from caps after the therapy caps are reached when evaluation is necessary, e.g., to determine if the current status of the beneficiary requires therapy services. For example, the following CPT codes for evaluation procedures may be appropriate: 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004.
ICD-10 Codes that Support Medical Necessity
ICD-10 CODE DESCRIPTION
F80.1 – F80.2 – Opens in a new window Expressive language disorder – Mixed receptive-expressive language disorder
F98.5 Adult onset fluency disorder
G52.2 – G52.8 – Opens in a new window Disorders of vagus nerve – Disorders of other specified cranial nerves
H90.0 – H90.12 – Opens in a new window Conductive hearing loss, bilateral – Conductive hearing loss, unilateral, left ear,
with unrestricted hearing on the contralateral side
H90.3 – H90.8 – Opens in a new window Sensorineural hearing loss, bilateral – Mixed conductive and sensorineural hearing
loss, unspecified
H93.241 – H93.243 – Opens in a new window Temporary auditory threshold shift, right ear – Temporary auditory threshold
shift, bilateral
H93.25 – H93.293 – Opens in a new window Central auditory processing disorder – Other abnormal auditory perceptions,
bilateral
I69.01 – I69.028 – Opens in a new window Cognitive deficits following nontraumatic subarachnoid hemorrhage – Other
speech and language deficits following nontraumatic subarachnoid hemorrhage
I69.090 Apraxia following nontraumatic subarachnoid hemorrhage
I69.092 Facial weakness following nontraumatic subarachnoid hemorrhage
I69.11 – I69.128 – Opens in a new window Cognitive deficits following nontraumatic intracerebral hemorrhage – Other
speech and language deficits following nontraumatic intracerebral hemorrhage
I69.190 Apraxia following nontraumatic intracerebral hemorrhage
I69.192 Facial weakness following nontraumatic intracerebral hemorrhage
I69.21 – I69.228 – Opens in a new window Cognitive deficits following other nontraumatic intracranial hemorrhage –
Other speech and language deficits following other nontraumatic intracranial hemorrhage
I69.290 Apraxia following other nontraumatic intracranial hemorrhage
I69.292 Facial weakness following other nontraumatic intracranial hemorrhage
I69.31 – I69.328 – Opens in a new window Cognitive deficits following cerebral infarction – Other speech and language
deficits following cerebral infarction
I69.390 Apraxia following cerebral infarction
I69.392 Facial weakness following cerebral infarction
I69.81 – I69.828 – Opens in a new window Cognitive deficits following other cerebrovascular disease – Other speech and
language deficits following other cerebrovascular disease
I69.890 Apraxia following other cerebrovascular disease
I69.892 Facial weakness following other cerebrovascular disease
I69.91 – I69.928 – Opens in a new window Cognitive deficits following unspecified cerebrovascular disease – Other
speech and language deficits following unspecified cerebrovascular disease
I69.990 Apraxia following unspecified cerebrovascular disease
I69.992 Facial weakness following unspecified cerebrovascular disease
J38.00 – J38.02 – Opens in a new window Paralysis of vocal cords and larynx, unspecified – Paralysis of vocal cords and
larynx, bilateral
R41.840 Attention and concentration deficit
R41.841 Cognitive communication deficit
R41.842 Visuospatial deficit
R41.843 Psychomotor deficit
R41.844 Frontal lobe and executive function deficit
R47.01 – R47.82 – Opens in a new window Aphasia – Fluency disorder in conditions classified elsewhere
R48.0 – R48.2 – Opens in a new window Dyslexia and alexia – Apraxia
R48.8 Other symbolic dysfunctions
R49.0 – R49.1 – Opens in a new window Dysphonia – Aphonia
Exceptions for Evaluation Services
Evaluation. The CMS will accept therapy evaluations from caps after the therapy caps are reached when evaluation is necessary, e.g., to determine if the current status of the beneficiary requires therapy services. For example, the following CPT codes for evaluation procedures may be appropriate: 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125. 97161, 97162, 97163, 97164, 97165, 97166, 97167, and 97168.
These codes will continue to be reported as outpatient therapy procedures as listed in the Annual Therapy Update for the current year at: http://www.cms.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage.
They are not diagnostic tests. Definitions of evaluations and documentation are found in Pub. 100-02, chapter 15, sections 220 and 230.
Other Services. There are a number of sources that suggest the amount of certain services that may be typical, either per service, per episode, per condition, or per discipline. For example, see the CSC – Therapy Cap Report, 3/21/2008, and CSC – Therapy Edits Tables 4/14/2008 at www.cms.hhs.gov/TherapyServices (Studies and Reports), or more recent utilization reports. Professional literature and guidelines from professional associations also provide a basis on which to estimate whether the type, frequency, and intensity of services are appropriate to an individual. Clinicians and contractors should utilize available evidence related to the patient’s condition to justify provision of medically necessary services to individual beneficiaries, especially when they exceed caps. Contractors shall not limit medically necessary services that are justified by scientific research applicable to the beneficiary. Neither contractors nor clinicians shall utilize professional literature and scientific reports to justify payment for continued services after an individual’s goals have been met earlier than is typical. Conversely, professional literature and scientific reports shall not be used as justification to deny payment to patients whose needs are greater than is typical or when the patient’s condition is not represented by the literature.
Required Reporting of Functional G-codes and Severity Modifiers
The functional G-codes and severity modifiers listed above are used in the required reporting on therapy claims at certain specified points during therapy episodes of care. Claims containing these functional Gcodes must also contain another billable and separately payable (non-bundled) service. Only one functional limitation shall be reported at a given time for each related therapy plan of care (POC).
Functional reporting using the G-codes and corresponding severity modifiers is required reporting on specified therapy claims. Specifically, they are required on claims:
• At the outset of a therapy episode of care (i.e., on the claim for the date of service (DOS) of the initial therapy service);
• At least once every 10 treatment days, which corresponds with the progress reporting period;
• When an evaluative procedure, including a re-evaluative one, ( HCPCS/CPT codes 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97161, 97162 ,97163, 97164, 97165, 97166, 97167, 97168) is furnished and billed;
• At the time of discharge from the therapy episode of care–(i.e., on the date services related to the discharge [progress] report are furnished); and
• At the time reporting of a particular functional limitation is ended in cases where the need for further therapy is necessary.
• At the time reporting is begun for a new or different functional limitation within the same episode of care (i.e., after the reporting of the prior functional limitation is ended)
Functional reporting is required on claims throughout the entire episode of care. When the beneficiary has reached his or her goal or progress has been maximized on the initially selected functional limitation, but the need for treatment continues, reporting is required for a second functional limitation using another set of Gcodes. In these situations two or more functional limitations will be reported for a beneficiary during the therapy episode of care. Thus, reporting on more than one functional limitation may be required for some beneficiaries but not simultaneously.
When the beneficiary stops coming to therapy prior to discharge, the clinician should report the functional information on the last claim. If the clinician is unaware that the beneficiary is not returning for therapy until after the last claim is submitted, the clinician cannot report the discharge status. When functional reporting is required on a claim for therapy services, two G-codes will generally be required.
Two exceptions exist:
1. Therapy services under more than one therapy POC– Claims may contain more than two nonpayable functional G-codes when in cases where a beneficiary receives therapy services under multiple POCs (PT, OT, and/or SLP) from the same therapy provider.
2. One-Time Therapy Visit– When a beneficiary is seen and future therapy services are either not medically indicated or are going to be furnished by another provider, the clinician reports on the claim for the DOS of the visit, all three G-codes in the appropriate code set (current status, goal status and discharge status), along with corresponding severity modifiers. Each reported functional G-code must also contain the following line of service information:
• Functional severity modifier
• Therapy modifier indicating the related discipline/POC — GP, GO or GN — for PT, OT, and SLP services, respectively
• Date of the related therapy service
• Nominal charge, e.g., a penny, for institutional claims submitted to the A/B MACs (A). For professional claims, a zero charge is acceptable for the service line. If provider billing software requires an amount for professional claims, a nominal charge, e.g., a penny, may be included. NOTE: The KX modifier is not required on the claim line for nonpayable G-codes, but would be requiredwith the procedure code for medically necessary therapy services furnished once the beneficiary’s annualcap has been reached.
The following example demonstrates how the G-codes and modifiers are used. In this example, the clinician determines that the beneficiary’s mobility restriction is the most clinically relevant functional limitation and selects the Mobility G-code set (G8978 – G8980) to represent the beneficiary’s functional limitation. The clinician also determines the severity/complexity of the beneficiary’s functional limitation and selects the appropriate modifier. In this example, the clinician determines that the beneficiary has a 75 percent mobility
restriction for which the CL modifier is applicable. The clinician expects that at the end of therapy the beneficiaries will have only a 15 percent mobility restriction for which the CI modifier is applicable. When the beneficiary attains the mobility goal, therapy continues to be medically necessary to address a functional limitation for which there is no categorical G-code. The clinician reports this using (G8990 – G8992). At the outset of therapy– On the DOS for which the initial evaluative procedure is furnished or the initial treatment day of a therapy POC, the claim for the service will also include two G-codes as shown below.
• G8978-CL to report the functional limitation (Mobility with current mobility limitation of “at least 60 percent but less than 80 percent impaired, limited or restricted”)
• G8979-CI to report the projected goal for a mobility restriction of “at least 1 percent but less than 20 percent impaired, limited or restricted.” At the end of each progress reporting period– On the claim for the DOS when the services related to the progress report (which must be done at least once each 10 treatment days) are furnished, the clinician will report the same two G-codes but the modifier for the current status may be different.
• G8978 with the appropriate modifier are reported to show the beneficiary’s current status as of this DOS. So if the beneficiary has made no progress, this claim will include G8978-CL. If the beneficiary made progress and now has a mobility restriction of 65 percent CL would still be the appropriate modifier for 65 percent, and G8978-CL would be reported in this case. If the beneficiary now has a mobility restriction of 45 percent, G8978-CK would be reported.
• G8979-CI would be reported to show the projected goal. This severity modifier would not change unless the clinician adjusts the beneficiary’s goal. This step is repeated as necessary and clinically appropriate, adjusting the current status modifier used as the beneficiary progresses through therapy.
CPT/ HCPCS Code
CPT Consumer Friendly Code Descriptions and Claim Line Outlier/Edit
Details PT Allowed Units OT Allowed Units SLP Allowed Units Physician/ NPP Not Under Therapy POC
92521 Evaluation of speech fluency 0 0 1 NA
92522 Evaluation of speech sound production 0 0 1 NA
92523 Evaluation of speech sound production with evaluation of language comprehension and expression 0 0 1 NA
92524 Behavioral and qualitative analysis of voice and resonance 0 0 1 NA
92597 Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech 0 0 1 NA
92607 Evaluation of patient with prescription of speech-generating and alternative communication device 0 0 1 NA
92611 Fluoroscopic and video recorded motion evaluation of swallowing function 0 1 1 1
92612 Evaluation and recording of swallowing using an endoscope Evaluation and recording of swallowing using an endoscope 0 1 1 1
92614 Evaluation and recording of voice box sensory function using an endoscope 0 1 1 1
92616 Evaluation and recording of swallowing and voice box sensory function using an endoscope 0 1 1 1
95833 Manual muscle testing of whole body 1 1 0 1
95834 Manual muscle testing of whole body including hands 1 1 0 1
96110 Developmental screening 1 1 1 1
96111 Developmental testing 1 1 1 1
97161 Evaluation of physical therapy, typically 20 minutes 1 0 0 NA
97162 Evaluation of physical therapy, typically 30 minutes 1 0 0 NA
97163 Evaluation of physical therapy, typically 45 minutes 1 0 0 NA
