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LCD ID Number: L33580 Status: A-Approved
LCD Title: Speech-Language Pathology
Geographic Jurisdiction: Rhode Island Other Jurisdictions
Original Determination Effective Date:
10/01/2015
Original Determination Ending Date:
Revision Effective Date:
12/19/2019
Revision End Date:
CMS National Coverage Policy:
Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.
Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:
Title XVIII of the Social Security Act (SSA):
Section 1833(e) of Title XVIII of the Social Security Act prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Section 1835(2)(D) of Title XVIII of the Social Security Act lists requirements for certification and recertification of outpatient speech-language pathology services.
Section 1862(a)(1)(A) of Title XVIII of the Social Security Act excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Section 1862(a)(7) excludes routine physical examinations, unless otherwise covered by statute.
Code of Federal Regulations:
42 CFR, Section 410.61 describes plan of treatment requirements.
42 CFR, Section 410.62 describes outpatient speech-language pathology services: Conditions and exclusions for Outpatient Speech Language Pathology (SLP).
42 CFR, Section 485.705 describes personnel qualifications.
CMS Publications:
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 12:
40.4 Speech-language pathology services
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:
220 Coverage of outpatient rehabilitation therapy services (physical therapy, occupational therapy, and speech-language pathology services) under medical insurance
220.1 Conditions of coverage and payment for outpatient physical therapy, occupational therapy, or speech-language pathology services
220.1.1 Outpatient therapy must be under the care of a physician/nonphysician practitioners (NPP) (orders/referrals and need for care)
220.1.3 Certification and recertification of need for treatment and therapy plans of care
220.1.4 Requirement that services be furnished on an outpatient basis
230.3 Practice of speech-language pathology
230.6 Therapy services furnished under arrangements with providers and clinics
CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Part 1:
50.2 Electronic speech aids
CMS Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Part 3:
170.2 Melodic intonation therapy
CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 5:
10.2 Financial limitation
20 HCPCS coding requirement
CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 6,
10.3 Types of services subject to the consolidated billing requirement for SNFs
CMS Transmittal No. 179, Publication 100-02, Medicare Benefit Policy Manual, Change Request #8458, January 14, 2014, provides revised portions of the relevant chapters of the program manual used by Medicare contractors, in order to clarify that coverage of skilled nursing and skilled therapy services “…does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.” Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition based on the Jimmo v. Sebelius Settlement Agreement.
CMS Transmittal No. 4149, Publication 100-04, Medicare Claims Processing Manual, October 23, 2018, removes Functional Reporting requirements and edits for outpatient therapy services.
CMS Transmittal No. 111, Publication 100-02, Medicare Benefit Policy Manual, Change Request #6005, September 25, 2009, advises that speech-language pathology therapy services are covered CORF services if physical therapy services are the predominate rehabilitation services.
CMS Transmittal No. 106, Publication 100-02, Medicare Benefit Policy Manual, Change Request #6381, April 24, 2009, advises that enrolled speech-language pathologists may bill for services provided on or after July 1, 2009.
CMS Transmittal No. 1717, Publication 100-04, Medicare Claims Processing Manual, Change Request #6381, April 24, 2009, advises that enrolled speech-language pathologists may bill for services provided on or after July 1, 2009.
CMS Transmittal No. 88, Publication 100-02, Medicare Benefit Policy Manual, Change Request #5921, May 7, 2008, Therapy Personnel Qualifications and Policies Effective January 1, 2008.
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