Description
Speech therapy is the treatment of communication impairment and swallowing disorders. Speech therapy services facilitate the development and maintenance of human communication and swallowing through assessment, diagnosis and rehabilitation.

Policy
Speech therapy services are considered MEDICALLY NECESSARY when used in the treatment of communication impairment or swallowing disorders due to disease, trauma, congenital anomalies, or prior therapeutic intervention.

For rehabilitative speech therapy, requests must meet ALL of the following criteria:

• Achieve a specific diagnosis related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable time period
• Provide specific, effective and reasonable treatment for the patient’s diagnosis and physical condition
• Be delivered by a qualified, licensed provider of speech therapy services
• Require the judgment, knowledge, and skills of a qualified provider of speech therapy services due to the complexity and sophistication and the physical condition of the patient

Initial approval if Medical Necessity criteria are met will be for 3 months (90 days).

• Guidelines for continuation of speech therapy:
  • Reasonable improvement and progression to completion of short- and long-term goals
  • Proof of progress within the approved timeframe
  • Proof of compliance with a Home Treatment Plan
  • Annual (every 12 months) retesting of speech delay for confirmation of improvement in level of function is required for continuation
    • Results will be compared to prior performance and deficiency gap to determine member-specific progression

A plan of care should include:

• Specific statements of long- and short-term goals.
• Measurable objectives.
• A reasonable estimate of when the goals will be achieved.
• The specific treatment techniques and/or exercises to be used in the treatment.
• The frequency and duration of treatment.

The plan of care should be should be updated and/or evaluated as the patient’s condition changes and should have recertification from the physician at least every 30 days.

PLEASE SEE SPECIFIC CONTRACT VERBIAGE FOR EXCLUSION, LIMITATIONS AND/OR MAXIMUMS RELATED TO PHYSICAL THERAPY, SPEECH THERAPY AND OCCUPATIONAL THERAPY.

NOTE: Homebound status is defined as an individual who normally would not be able to leave the home, however, due to illness or injury leaving the home will now require considerable and taxing effort. An aged person who does not travel from their home because of feebleness and insecurity brought on by advanced age is NOT considered homebound. Requests for habilitative speech therapy performed in the home will be reviewed on a case-by-case basis.

Rationale
A search of literature was completed through the MEDLINE database for the period of January 1990 through October 1995. The search strategy focused on references containing the following Medical Subject Heading:

— Speech Therapy

Documentation Requirements:

Provider Record-Keeping Requirements for Modalities and Therapeutic Procedures

Definitions

Modality/Modalities: Current Procedural Terminology (CPT) Codes 97010 through 97039.

Therpaeutic Procedure(s): CPT Codes 97110 through 97564.

Timed Codes: Those Modalities and Therapeutic Procedures which contain the phrase "each 15 minutes" in their code descriptors. For example, CPT code is a timed code. The descriptor for CPT Code 97110 reads "Therapeutic procedure, 1 or more areas, each 15 minutes: therapeutic exercises to develop strength and endurance, range of motion and flexibility."

General Requirements

Providers must maintain medical records which comport with the record keeping standards of their profession. However, to the extent the provider’s profession’s record keeping standards do not already require it, for a provider to be reimbursed for claims for modalities and/or therapeutic procedures his or her medical records must also comply with the following requirements: 

1. The date and the patient’s name must appear on each page of the patient’s medical records.
2. Each patient encounter must be a separate record.
3. The patient’s entire record must be legible (i.e., must be legible to someone other than the writer).
4. Entries in the medical record must be made within a week of the provider performing the modalities and/or therapeutic procedures.
5. The medical record must demonstrate that the modalities and/or therapeutic procedures are medically necessary.
6. The medical records must demonstrate that the patient’s treatment plan is consistent with his or her diagnoses.
7. CPT codes and ICD codes reported on claim forms or billing statements are supported by the documentation in the medical record.
8. The provider must provide a definition sheet of abbreviations specific to his or her office to assist BlueCross in interpreting patients’ medical records.
9. Documentation corrections should be single line drawn through the error with the corrected text in close proximity, initialed and dated by the person who made the error.

Treatment Notes/Patient Encounter Notes

In addition, to the extent the provider’s profession’s record keeping standards do not already require it, for a provider to be reimbursed for claims for modalities and/or therapeutic procedures the following information must be recorded by the provider in each individual record of a patient encounter.

1. A description, not a reiteration of the CPT code, of each individual modality and therapeutic procedure provided and billed in language that can be compared with the billing on the claim to verify correct coding.
2. For timed codes, an indication of the total number of minutes each individual modality and therapeutic procedure was performed.
3.  A description of the specific area of the patient’s body to which each individual modality and therapeutic procedure was directed and/or performed.
4. The legible signature and professional identification of the individual who furnished each individual modality or therapeutic procedure.
5. The patient’s response to the treatment.
6. A skilled ongoing reassessment of the patient’s progress toward treatment goals.
7. A description of the patient’s progress toward the goals in objective, measurable terms using consistent and comparable methods.
8. A description of any patient problems or changes to the plan of care.
9. A description of the reason for the encounter.
10. A date for a return visit or follow-up plan.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2024 Forward      

08/13/2024 Removing the following statement REMINDER: BlueCross BlueShield of South Carolina does not recognize incident-to-billing but requires that claims be billed under the name of the provider who actually rendered the service, modality or therapeutic procedure. 

06/19/2024 Annual review. No changes to policy intent. 

01/01/2024 NEW POLICY