Speech Therapy 1
This section contains information about speech therapy services and program coverage (California Code
of Regulations [CCR], Title 22, Section 51309). For additional help, refer to the speech therapy billing example section in the appropriate Part 2 manual.
Notice: Assembly Bill X3 5 (Evans, Chapter 20, Statutes of 2009) excluded various optional
benefits from coverage under the Medi-Cal program, including speech therapy
services. Refer to the Optional Benefits Exclusion section in this manual for policy
details, including information regarding exemptions to the excluded benefits. All
codes listed in this section are affected by the optional benefits exclusion policy.
Program Coverage In addition to the policy described in the Optional Benefits Exclusion
section, Medi-Cal covers speech therapy services only when ordered
on the written referral of a physician or dentist.
(CCR, Title 22, Section 51309[a])
Eligibility Requirements Providers should verify the recipient’s Medi-Cal eligibility for the
Medi-Services A Medi-Service reservation is necessary for each outpatient speech
therapy visit provided by an independent practitioner. Visits to a
Medi-Cal recipient in a nursing facility do not require a Medi-Service
reservation; however, authorization is required.
Information about how to reserve a Medi-Service is contained in the
* If using the Automated Eligibility Verification System (AEVS),
refer to the AEVS: Transactions section of the Part 1 manual.
* If using a Point of Service (POS) device, refer to the POS:
Eligibility Transaction Procedures section in the POS Device
* If using the Internet, refer to the Medi-Cal Web Site Quick Start
“Visit” Defined “Visit” is defined as any covered speech therapy procedure or
combination of procedures performed on the same day.
Recipients Under Age 21 Additional speech therapy services for full scope Medi-Cal recipients
under 21 years of age are available through Early and Periodic
Screening, Diagnosis and Treatment (EPSDT) Supplemental
Services, subject to authorization, where medically necessary.
2 – Speech Therapy June 2009
Per CCR, Title 22, Section 51013, Medi-Cal eligible recipients under
21 years of age with hearing loss are to be referred to California
Children’s Services (CCS) for case management and authorization of
services. Medical eligibility for the CCS program for hearing loss is
defined in CCR, Title 22, Section 41839. Refer to the California
Children’s Services (CCS) and Genetically Handicapped Persons
Program (GHPP) section in the appropriate Part 2 manual for
Written Referral Speech pathologists are reimbursed for services only if the services Requirements are performed in response to the written referral of licensed
practitioners, acting within the scope of their practice.
The Medi-Cal program definition of medical necessity limits health
care services to those necessary to protect life, to prevent significant
illness or significant disability, or to alleviate severe pain. It is
important that the referring practitioner supply the therapist with the
information required to document the medical necessity.
The following information must be included on the written referral:
; Signature of the referring practitioner
; Name, address and telephone number of the referring
; Date of the referral
; Medical condition necessitating the service(s) (diagnosis)
; Supplemental summary of the medical condition or functional
limitations must be attached or included in the referral
; Specific services (for example, evaluation, treatments,
; Frequency of services
; Duration of medical necessity for services – specific dates and
length of treatment should be identified if possible. Duration of
therapy should be set by the referring practitioner; however,
referrals are limited to six months.
; Anticipated medical outcome as a result of the therapy
; Date of progress review (when applicable)
Speech Generating Speech therapy services related to speech generating devices are Devices: Related not affected by the optional benefit exclusion policy and remain Speech Therapy Services reimbursable. The following speech therapy codes remain
reimbursable for all beneficiaries:
2 – Speech Therapy June 2009
Recipient Information The following recipient information should be included on each
written referral, when applicable:
; Developmental status and rate of achievement of
; Mental status and ability to comprehend
; Related medical conditions
The goal of therapy should be achievement of intelligibility rather than
age-specific qualities or previous condition status, such as with a
Prior Authorization Treatment Authorization Requests (TARs) for speech therapy for
Medi-Cal-only recipients must be submitted to the San Francisco
Medi-Cal Field Office. Refer to the TAR Field Office Addresses
section in this manual for details.
Speech therapy services rendered in an outpatient setting are limited
to a maximum of two services per month subject to the availability of
Medi-Service reservations. Initial and six-month evaluations do not
require prior authorization.
Certified Rehabilitation Authorization procedures for speech therapy services rendered in a Centers and Nursing Facilities certified rehabilitation center or Nursing Facility (NF) Level A or B are:
; The Medi-Service reservation limitation of two services per
month does not apply.
; Initial and six-month evaluations do not require prior
authorization. For billing instructions, refer to “Initial and
Six-Month Evaluations” in this section.
; Authorization is required for any additional speech therapy
service beyond the initial and six-month evaluation. 2 – Speech Therapy June 2001
Nursing Facility Prior Speech therapy services rendered to NF-A or NF-B recipients Authorization Requirements: require prior authorization. A TAR must be submitted for services
(Valdivia v. Coye) are not included in the Medi-Cal inclusive per diem rate for an NF.
For specific TAR requirements, refer to the TAR Criteria for NF
Authorization (Valdivia v. Coye) section in this manual.
Initial and Six-Month Initial and six-month evaluations billed with HCPCS code X4308 Evaluations (speech) require only that the recipient be eligible for the Medi-Cal
month during which the service is performed in a certified
rehabilitation center, NF-A or NF-B, or pediatric subacute care facility
on the written order of the attending physician.
Claim Information The statement “Initial evaluation visit” or “Six-month re-evaluation
visit” must be entered in the Remarks area/Reserved For Local Use
field (Box 19) of the claim when speech therapy services are billed.
The initial evaluation document is not required as an attachment to
the claim form.
Note: Services provided in a board and care facility are billed with a
Place of Service code “12” (home) and require a Medi-Service
2 – Speech Therapy June 2001
Required Professional Licensed speech pathologists may be reimbursed for covered Experience Services: Medi-Cal services performed by unlicensed speech pathologists Reimbursable working under their direct supervision to fulfill Required Professional
Experience (RPE) for licensure.
Requirements for this policy are:
; The RPE trainee must have completed the required academic
training and be acquiring the RPE as necessary for licensure.
; Speech pathologists wishing to use an RPE trainee to treat
Medi-Cal recipients must be approved by the Provider
Section of the Department of Health Care Services (DHCS).
The supervising provider must apply to DHCS to obtain an
trainee rendering provider number for the trainee. This
number will have an automatic expiration date.
; Interested providers must contact DHCS RPE Services at
(916) 323-1945 for approval to bill RPE services.
The supervising provider must bill for the services and enter the
RPE trainee’s provider number in the Reserved for Local Use field
(Box 24K) of the claim. Providers billing for services performed by an
RPE trainee must add modifier YW to HCPCS codes X4300 – X4320
for speech therapy.
Speech Generating For more information, refer to the Speech Generating Devices (SGD)
Devices (SGD) section in the appropriate Part 2 manual.
2 – Speech Therapy November 2007