Speech Therapy (speech)

By Gregory Lawrence,2014-05-09 22:31
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Speech Therapy (speech)


    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


     of service.

    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

    following documents:

    * 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

    User Guide.

    * 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

    additional information.

    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,

    modalities) requested

    ; 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

    (therapeutic goals)

    ; 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:

    ; Age

    ; Developmental status and rate of achievement of

    developmental milestones

    ; 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

    stroke victim.

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

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