ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Speech Therapy 06.01.24

Defines coverage, prerequisites, authorization requirements, exclusions, documentation and coding rules for outpatient speech-language pathology services for Medicaid, INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySpeech Therapy 06.01.24

Policy CodePolicy N/A

Change TypeAuthorization language updated; multiple coding and visit limit updates

Effective Date06-15-2024

Next Review Date

Key ActionObtain and document an order for outpatient therapy from the PCP or treating physician (separate and distinct from therapy provider) and record referring provider in the medical record and Box 17 on the claim.

SourceLink

POLICY UPDATE CHANGES

06/01/2024 Annual Review. Updated authorization language for Medicaid and Commercial.

10/01/2023 Updated visit limits and authorization requirement language for Integrity.

04/18/2023 Annual Review. Removed exclusion for group therapy and added CPTs 97129 and 97130 and direction on using GN modifier with Medicare Sometimes/Always Therapy codes.

11/15/2022 Added CPT 92597.

04/12/2022 Annual Review, no changes.

03/01/2022 Update to include requirement for referring provider.

04/01/2021 Remove benefit limit of 24 visits for Medicaid and Commercial LOB's effective 4/1/21.

24INTEGRITY no-auth visits per discipline per calendar year

06-15-2024

Authorization required for Commercial/Medicaid effective

8+CPT codes explicitly listed

Coverage Summary

High-level coverage: This policy defines outpatient speech-language therapy coverage for Medicaid (excluding Extended Family Planning), INTEGRITY, and Commercial lines of business.

Authorization and visit limits summary: INTEGRITY allows no authorization for the first 24 visits per calendar year per discipline (Physical, Occupational, Speech); prior authorization is required for visits exceeding 24. For Commercial and Medicaid, Neighborhood partners with Evolent Health (effective 06/01/2024) and authorization is required for all speech therapy services as of 06/15/2024.

Additional rules: Billing for certain Medicare sometimes/always therapy CPTs requires appending the GN modifier (claims without required modifier will deny).

Key Facts

INTEGRITY no-auth visits per discipline per calendar year24

Authorization required for Commercial/Medicaid effective06-15-2024

CPT codes explicitly listed (examples)92507, 92508, 92526, 92608, 92609, 92610, 97129, 97130, 92521, 92522, 92523, 92524, 92597, 92607, S9152

Last review date2024-06-01

Has material changetrue

Medical-Necessity Criteria

General Medical Necessity

Covered when ALL of the following are met:

ALL of the following

Services assist with development of human communication and evaluate and/or treat speech, language, cognitive-linguistic, feeding, or swallowing impairments related to a specific illness, injury, or congenital or neurodevelopmental condition.
Services are medically necessary as determined by Neighborhood using NCD, LCD, industry accepted criteria (e.g., InterQual), EOHHS recommendations, and Clinical Medical Policies.
Treatment goals systematically address a specific diagnosis, deficit, or dysfunction with reasonable expectation of measurable improvement in a reasonable and predictable period of time.
Treatment modalities are evidence-based and available within the Neighborhood network.

Not Covered / Exclusions

Coverage Exclusions (Not Covered)

Services are NOT covered when ANY of the following apply:

ANY of the following

Therapy for a condition when the therapeutic goals of a treatment plan have been achieved and no progress is apparent or expected to occur.
Non-skilled services, including treatments not requiring skills of a qualified provider or procedures that may be carried out effectively by the child, family or caregivers.
Maintenance programs, including drills, techniques and exercises that preserve present level of function and prevent regression.
Swallowing/feeding therapy for food aversions or food selectivity NOT resultant from an underlying medical condition or neurodevelopmental disorder, unless there is weight loss and risk of failure to thrive.

Coding

Medicare Sometimes/Always Therapy Speech Therapy Evaluation and Treatment Codes — must append GN modifierCPTCovered

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals
92526	Treatment of swallowing dysfunction and/or oral function for feeding
92608	Therapeutic services for the use of speech-generating device (procedure)
92609	Therapeutic services for the use of speech-generating device, including programming and modification
92610	Evaluation of oral and pharyngeal swallowing function
97129	Cognitive therapy: initial 15 minutes, direct (one-on-one) patient contact
97130	Cognitive therapy: each additional 15 minutes (list separately)

Speech Therapy Evaluation CodesCPTCovered

92521	Evaluation of speech fluency (eg, stuttering, cluttering)
92522	Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)
92523	Evaluation of speech sound production with evaluation of language comprehension and expression
92524	Behavioral and qualitative analysis of voice and resonance
92597	Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech
92607	Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour
S9152	Speech therapy code (HCPCS) — listed in policy

GN modifier: Modifier used to distinguish the discipline under which the service was delivered per CMS Medicare sometimes/always therapy coding guidance; required on specified codes.

Note: The GN modifier must be appended to the listed Medicare sometimes/always therapy codes when applicable. Claims submitted without the required modifier will be denied.

Provider Actions & Billing Rules

Prior Authorization

Order and Referring Provider Documentation

Obtain and document an order for outpatient therapy from the member's PCP or treating physician that is separate and distinct from the practice providing therapy. Document the ordering/referring provider in the member's medical record and include the referring provider in Box 17 on the claim.

Prior Authorization

INTEGRITY: Visits Authorization Threshold

No authorization is needed for the first 24 visits per calendar year per discipline (Physical, Occupational, Speech Therapy). Prior authorization is required for any visits exceeding 24 per calendar year per discipline.

Background

Scope of services: Speech-language therapy addresses communication, cognitive-linguistic, feeding, and swallowing impairments related to medical, congenital, injury, or neurodevelopmental conditions.

Coverage is contingent on medical necessity as determined using NCD/LCD, industry-accepted criteria (e.g., InterQual), EOHHS recommendations, and Clinical Medical Policies, and requires documented orders/referrals from the PCP or treating physician that are separate and distinct from the therapy provider.

Treatment must use evidence-based modalities, have goals that address a specific diagnosis or deficit with reasonable expectation of measurable improvement, and documentation in the medical record must support billed services and medical necessity.

Early Intervention: Children up to age 3 with developmental delays and related conditions should be referred to Early Intervention for evaluation and treatment prior to requesting services from Neighborhood.

Definitions

GN modifier — definition: Modifier to distinguish the discipline under which the service was delivered per CMS Medicare sometimes/always therapy coding guidance; required on specified codes.

Application: Append the GN modifier to the Medicare sometimes/always therapy speech therapy evaluation and treatment codes listed in the policy; failure to append the required modifier will result in claim denials.

Revision History

06/01/2024annual_reviewLatest

Annual Review. Updated authorization language for Medicaid and Commercial. Evolent Health partnership effective June 1, 2024; authorization required for all speech therapy services as of June 15, 2024.

10/01/2023revised

Updated visit limits and authorization requirement language for INTEGRITY; clarified 24-visit no-authorization threshold and prior authorization requirement thereafter.

04/18/2023annual_review

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySpeech Therapy 06.01.24

Policy CodePolicy N/A

Change TypeAuthorization language updated; multiple coding and visit limit updates

Effective Date06-15-2024

Next Review Date

SourceLink

On This Page

Children up to age 3 with developmental delays should be referred to Early Intervention prior to requesting services from Neighborhood.

Prerequisite: Order/Referring Provider

ALL of the following

Members must receive an order for outpatient therapy services from their PCP or treating physician that is separate and distinct from the practice providing therapy.
The ordering/referring provider must be documented in the member's medical record and noted in Box 17 (referring provider) on the claim.

INTEGRITY Authorization Rule

ALL of the following

No authorization needed for the first 24 visits per calendar year per discipline (Physical, Occupational, Speech Therapy).
Prior authorization is required for anything over 24 visits per calendar year per discipline.

Commercial and Medicaid Authorization Rule (effective June 2024)

Oral sensorimotor therapy or myofunctional therapy as isolated therapy for tongue thrust, deviant or reverse swallow, or oral myofunctional disorders in members without a diagnosed neuromuscular disease.

Vocational rehabilitation, testing and screening focusing on job adaptability or placement.

Rehabilitative services to restore function for a member's specific occupation.

Services provided solely for the convenience of the member or service provider.

Services associated with use of Altered Auditory Feedback (AAF) devices, including the devices.

Conditions appropriate for behavioral management rather than medical/rehabilitative therapies.

Services that would result in duplicative or substantially identical services as those provided by another Medicaid funded service.

Prior Authorization

Commercial & Medicaid Authorization Effective 2024-06-15

Authorization is required for all speech therapy services for Commercial and Medicaid lines effective June 15, 2024. Neighborhood is partnering with Evolent Health to manage physical medicine services effective June 1, 2024.

Documentation Required

Medical Record Documentation

Maintain medical record documentation that supports the services billed and the medical necessity of those services. Neighborhood may request medical records for any billed service and follows CMS standards for proper documentation requirements.

Billing Rule

GN Modifier Requirement

Append the GN modifier to the listed Medicare Sometimes/Always Therapy speech therapy evaluation and treatment codes. Claims submitted without the required GN modifier will deny.

92507
92508
92526
92608
92609
92610
97129
97130

Billing Rule

Timely Filing

Submit complete claims for billable services within the contractually determined timely filing guidelines. Billable services are subject to contractual agreements.

Annual Review. Removed exclusion for group therapy and added cognitive therapy CPTs 97129 and 97130 with direction on using GN modifier for Medicare Sometimes/Always therapy codes.

11/15/2022added

Added CPT 92597 to the Speech Therapy Evaluation Codes list.

04/12/2022annual_review

Annual Review, no changes.

03/01/2022revised

Update to include requirement that the ordering/referring provider be documented and distinct from the therapy provider (referencing documentation in medical record and Box 17).

04/01/2021removed

Removed benefit limit of 24 visits for Medicaid and Commercial lines effective 04/01/2021 (subsequently modified by later updates).