CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Outpatient Speech‑Language Therapy — Coverage Criteria

Defines coverage, authorization, coding, exclusions, and documentation requirements for outpatient speech‑language therapy for Neighborhood Health Plan members across Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOutpatient Speech‑Language Therapy — Coverage Criteria

Policy CodePolicy N/A

Change TypeUpdated visit limits and authorization languageadded CPTs and modifier guidance

Effective DateN/A

Next Review DateN/A

Key ActionObtain and document an order/referral from the member's PCP or treating physician separate and distinct from the therapy practice.

SourceLink

POLICY UPDATE CHANGES

Updated visit limits and authorization requirement language for INTEGRITY.

Added CPT 92597.

Added CPTs 97129 and 97130 and direction on GN modifier with Medicare Sometimes/Always Therapy codes.

24visits per discipline without prior auth

24visits per discipline referenced

10/01/2023last action date

Coverage Criteria for Outpatient Speech-Language Therapy

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There is a recommendation/order from a medical provider and an order/referral documented that is separate and distinct from the treating therapy practice.

Services address a specific illness, injury, congenital, or neurodevelopmental condition causing a documented speech, language, cognitive-linguistic, feeding, or swallowing impairment.

The treatment is evidence-based, systematically addresses the diagnosis/deficit, and the patient has a reasonable expectation of measurable improvement in a reasonable and predictable period of time.

Speech-language services are not covered when they are non-skilled or can be performed effectively by the child, family, or caregivers; when therapeutic goals have been achieved and no further progress is expected; or when provided as a maintenance program (drills, techniques, or exercises intended only to preserve current function). The policy also excludes isolated oral sensorimotor/myofunctional therapy for tongue thrust, deviant/reverse swallow, or other oral myofunctional disorders in members without a diagnosed neuromuscular disease.

Maintenance programs and interventions are considered not medically necessary when goals have been met or when no measurable progress is expected. Interventions that are non‑skilled and can be performed by caregivers or family members are excluded from coverage. Additionally, feeding/swallowing therapy for food aversions or selectivity is not covered unless there is an underlying medical condition or neurodevelopmental disorder associated with weight loss or risk of failure to thrive.

Relevant CPT/Modifier Coding

Medicare Sometimes/Always Therapy Speech Therapy Evaluation and Treatment CodesCPT

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	92526
92608	Each additional 30 minutes (speech-generating device eval add-on)
92610	Evaluation of oral and pharyngeal swallowing function
97129	Therapeutic interventions that focus on cognitive function; initial 15 minutes
97130	Therapeutic interventions that focus on cognitive function; each additional 15 minutes

Speech Therapy Evaluation and Treatment CodesCPT

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; first hour
S9152	Speech re-evaluation therapy

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization / Visit Limit

INTEGRITY: No prior authorization is required for the first 24 outpatient speech therapy visits per calendar year for INTEGRITY members. Prior authorization is required for any visits beyond 24 per calendar year.

24 visits per discipline (Physical, Occupational, Speech Therapy)

Denial Risk

Modifier Omission Triggers Denial

If the required GN modifier is not appended to the listed therapy CPT codes, claims will deny. Providers must append the GN modifier to Medicare 'sometimes/always' therapy speech therapy codes to indicate the discipline under which the service was delivered.

Examples include CPTs listed in the policy (e.g., 92507, 92508, 92526, 92608, 92610, 97129, 97130).

Documentation Required

Documentation Must Support Medical Necessity

Providers must have and maintain documentation supporting the medical necessity of services and the ordering/referring provider. Neighborhood reserves the right to request medical records for any billed service; lack of supporting documentation may result in denial or audit.

Documentation must follow CMS standards for proper documentation.
Neighborhood may use LCD, NCD, InterQual, and Clinical Medical Policies to determine medical necessity.

Billing Rule

Ordering / Referral Requirement

Providers must obtain an order for outpatient services from the member's 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 reported in Box 17 (referring provider) on the claim.

Order must be separate and distinct from the therapy practice providing services.
Box 17 on the claim must list the referring provider.

Denial Risk

Documentation / Order Missing — Denial Risk

Absence of a documented order/referring provider in the medical record or lack of documentation supporting medical necessity may trigger claim denial or audit. Providers are responsible for verifying eligibility, coverage, and authorization criteria prior to rendering services.

Neighborhood may request medical records and will use them to validate medical necessity.
Failure to document the ordering/referring provider in the medical record and Box 17 may result in denial.

Definitions

inv-12: Speech-language therapy — definition and scope of services

DefinitionSpeech-language therapy services assist with the 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.

Scope — clinical targetsEvaluation and treatment of speech, language, cognitive-linguistic, feeding, and swallowing impairments tied to a documented diagnosis, deficit, or dysfunction.

Treatment expectationsServices must be evidence-based, systematically address the diagnosis/deficit, and aim for measurable improvement within a reasonable and predictable period.

Referral for young childrenChildren up to age three with developmental delays should be referred to Early Intervention for evaluation and treatment prior to requesting services from Neighborhood.

Network and modality requirementsTreatment modalities should be evidence-based and available within the Neighborhood network.