Q: What are Speech-Language Pathology Services?
A: Services requiring the application of theories, principles and procedures related to the development and disorders of speech, voice, language and oral pharyngeal and related functions, for purposes of assessment and treatment.[1]
Q: What are Audiology Services?
A: Services requiring the application of theories, principles and procedures related to hearing and hearing disorders for the purpose of assessment and treatment.[2]
Q: Do Speech-Language and Audiology Services have to be “Medically Necessary?”
A: Yes. [3]
Q: What is “Medically Necessary?”
A: Reasonably necessary and remedial services that are provided in an appropriate setting; recognized as standard medical care based on national standards for best practices and safe, effective, quality care; required for the diagnosis, prevention and/or treatment of illness, disability, infirmity or impairment and which are necessary to improve, restore or maintain health and well-being; are MaineCare covered services; performed by enrolled providers within their scope of licensure and/or certification and are provided within the regulations of the Maine Care Benefits Manual.[4]
Q: Are there particular “settings” in which speech and hearing services can be delivered?
A: Yes: Practitioner’s offices, speech and hearing agencies, schools when the child is under the age of 21 and children’s homes. In addition, services may be provided in an alternative setting at the practitioner’s discretion when the following conditions are met:
- The services are medically necessary.
- The setting is conducive to the services being provided.[5]
Q: Who can “order” or “request” in writing Speech-Language Pathology Services?
A: A practitioner of the healing arts, as allowed by the respective licensing authority and his or her scope of practice.[6]
Q: Must a “Plan of Care” be generated for all Speech-Language and Hearing Services?
A: Yes.[7]
Q: What is a “Plan of Care?”
A:
- A prerequisite to aural rehabilitation and speech-language therapy; and
- Documents Diagnosis with severity rating;
- Documents short and long term obtainable goals and objectives; (the plan must also be updated in relation to the child’s progress in reaching the goals)
- Documents method of evaluating child’s change;
- Documents estimated time to achieve goals and objectives;
- Documents frequency and duration of therapy contacts;
- Documents periodicity of review;
- Documents identified problems; and
- Documents treatment in relation to the problems[8]
Q: What are the “covered” Speech-Language Pathology Services?
A:
- Speech, Voice and Language Evaluation, Diagnosis and Plan of Care by Speech-Language Pathologist
- Speech, Voice and Language Therapy and/or Aural Rehabilitation, Individual or Group
- Speech and Language Periodic Re-Evaluation
- Speech Pathology Diagnostic Services at Physician or PCP’s Request
- Hearing Screening by a Speech-Language Pathologist
- Speech, Voice and/or Language Screening
- Augmentative and Alternative Communication Evaluation Services
- Therapeutic Adaptations and Set-Up for Assistive/Adaptive Equipment
- Reprogramming
- Audiologic Evaluation, Diagnosis and Plan of Care, by Audiologist
- Audiologic Evaluation for Persons Difficult to Test
- Audiologic Evaluation for Site of Lesion
- Audiologic Evaluation as a Result of Change in Hearing Status because of Disease or Trauma
- Audiologic Diagnostic Services at Physician or PCP’s Request
- Aural or Language Rehabilitation (including speech reading) Individual and Group by Audiologist
- Hearing Aid Evaluation and Related Procedures, by Audiologist
- Hearing and/or Hearing Aid Periodic Recheck
- Hearing Screening for Children up to Age 5 by an Audiologist
- Ear Molds[9]
Q: Generally, who is qualified to deliver speech services?
A: A licensed Speech-Language Pathologist, a licensed Audiologist, and a registered Speech-Language Pathology Assistant.[10] In addition, an individual who is temporarily licensed as a Speech-Language Pathologist who is supervised and trained by a licensed Speech-Language Pathologist may also seek Medicaid reimbursement.[11]
Q: Who is a licensed Speech-Language Pathologist?
A: A Speech-Language Pathologist that holds a valid license from the State or Province in which the services are provided.[12]
Q: Who is a licensed Audiologist?
A: An Audiologist who holds a valid license for the State or Province in which the services are provided.[13] In addition, an individual who is temporarily licensed as an Audiologist who is supervised and trained by a licensed Audiologist may also seek Medicaid reimbursement.[14]
Q: Who is a registered Speech-Language Pathology Assistant?
A: A Speech-Language Pathology Assistant who is registered as a Speech- Language Pathology Assistant by the Maine Board of Examiners on Speech-Language Pathology and Audiology, as documented by written evidence by such Board, or registered in accordance with the licensure of the State or Province in which services are provided. A Speech-Language Pathology Assistant must be supervised by a Licensed Speech-Language Pathologist.[15]
Q: What are Speech, Voice and Language Evaluation, Diagnosis and Plan of Care by Speech-Language Pathologist Services?
A: A direct encounter between a licensed Speech-Language Pathologist and the child to determine the status of both receptive and expressive communication skills.[16]
Q: What are Voice and Language Therapy and/or Aural Rehabilitation, Individual or Group Services?
A: The process of producing behavioral change in a child with a communication disorder involving a one to one or group relationship by a licensed Speech-Language Pathologist or a registered Speech-Language Pathology Assistant and following a Plan of Care.[17]
Q: What are Speech and Language Periodic Re-Evaluation Services?
A: A direct encounter between a child and Speech-Language Pathologist to determine current status with periodicity determined by plan of care.[18]
Q: What are Speech Pathology Diagnostic Services at Physician or PCP’s Request?
A: Specialty testing by a Speech-Language Pathologist to assist in diagnosis and development of a medical plan of care. Report will include the Pathologist’s recommendations. Currently acceptable medical tests and procedures are to be utilized as medically necessary.[19]
Q: What is a Hearing Screening by a Speech-Language Pathologist?
A: Pure tone air conduction testing by a Speech-Language Pathologist as part of a hearing screening program.[20]
Q: What is a Speech, Voice and/or Language Screening?
A: A Speech, Voice and/or Language Screening performed by a licensed Speech-Language Pathologist or a registered Speech-Language Pathology Assistant as part of a screening.[21]
Q: What are Augmentative and Alternative Communication Evaluation Services?
A: Diagnostic, screening, preventative and corrective services provided by a licensed Speech-Language Pathologist or registered Speech-Language Pathology Assistant. Specific activities include evaluation for, recommendation of, design, set up, customization, reprogramming, maintenance and training related to the use of an Augmentative and Alternative Communication Device (AACD)[22]
Q: What is an “AACD?”
A: Electronic or non-electronic aides, devices or systems and related components, accessories and supplies that assist in overcoming or ameliorating the communication limitations that preclude or interfere with meaningful participation in current and projected daily activities.[23]
Q: What are Therapeutic Adaptations and Set-Up for Assistive/Adaptive Equipment?
A: Customizing the operational characteristics of an AACD in order to meet the needs of a child and maximize the use and effectiveness of the AACD. These tasks must be performed by a licensed Speech-Language Pathologist[24]
Q: What is “Reprogramming?”
A: Any necessary reprogramming of AACD equipment. It must be performed by a licensed Speech-Language Pathologist or registered Speech-Language Pathology Assistant familiar and experienced with AACD.[25]
Q: What is Audiologic Evaluation, Diagnosis and Plan of Care, by Audiologist?
A: A direct encounter between a child and an Audiologist to determine the child’s hearing status.[26]
Q: What is Audiologic Evaluation for Persons Difficult to Test?
A: Based on a written plan of care serial evaluation for persons difficult to test in order to obtain reliable audiologic information necessary for case management. This service must be based on a plan of care and must be delivered by an Audiologist.[27]
Q: What is Audiologic Evaluation for Site of Lesion?
A: A direct encounter between a child and an Audiologist which determines the site of lesion. The evaluation may include the following tests: pure tone air, pure tone bone, speech audiometry, Bekesy, tone decay, short increment sensitivity index, impedance, alternate binaural loudness balance tests.[28]
Q: What is Audiologic Evaluation as a Result of Change in hearing Status because of Disease or Trauma?
A: An audiologic evaluation necessitated by an observed or suspected change in a child’s hearing status because of disease or injury on referral from a Physician or PCP.[29]
Q: What are the limits on audiology evaluations?
A: If an evaluation has already been performed by another Audiologist within the previous 4 months, Prior Authorization by DHHS is required.[30]
Q: What are Audiologic Diagnostic Services at Physician or PCP’s Request?
A: Specialty testing performed by an Audiologist to assist in diagnosis and developing a medical plan of care, which must include the Audiologist’s recommendations.[31]
Q: What are Aural or Language Rehabilitation (including speech reading) Individual and Group Services by Audiologist?
A: The process of producing behavioral change in a child or children presenting communication disorders related to auditory function, involving a one-to-one or group relationship following a Plan of Care. These rehabilitation services include cochlear implant follow-up aural rehabilitation services. In this context, “group” means 2 to 4 individuals with one clinician.[32]
Q: What are Hearing Aid Evaluation and Related Procedures by Audiologist?
A: Demonstrating a hearing aid and the process of familiarizing a child with the basic features of a hearing aid by providing the opportunity to experience hearing with a hearing aid, and comparing performance with and without amplification as part of a program of rehabilitation. This service must be documented by an Audiologist’s report, which includes recommendations for amplification and data to support the recommendations.[33]
Q: What is a Hearing and/or Hearing Aid Periodic Recheck?
A: A direct encounter between a child and an Audiologist to determine current hearing and/or hearing aid status. The frequency of rechecks must be outlined in the Plan of Care.[34]
Q: What records need to be retained?
A:
- Name, birthdate, Medicaid #;[35]
- Referral from a practitioner of the healing arts, as allowed by the respective licensing authority and within scope of practice, made in writing prior to the delivery of service;[36]
- Pertinent medical information;[37]
- Appropriate hearing and/or speech-language evaluation and diagnosis;[38]
- Plan of Care;[39]
- Documentation of each visit, showing the date of service, the nature of the service performed, the start and stop time of the service, indicating the total time spent in delivering the service, and the signature of the individual performing the service;[40]
- Progress notes written at least quarterly which state the progress which the child has made in relation to the Plan of Care;[41]
- A discharge summary with a copy sent to the referring practitioner of the healing arts[42]; and
- Any other pertinent information concerning the child (but not a prior authorization, except where required for an Audiology Evaluation when a previous evaluation was done in the previous four months).[43]
Q: May schools submit claims for Speech & Hearing Services?
A: Public schools will be considered just as any other qualified community-based MaineCare provider. Schools will be able to re-enroll in MIHMS and bill MaineCare on behalf of the Speech-Language Pathologists the schools employ. If the Speech-Language Pathologists being utilized by the school are contracted staff, the school district may bill MaineCare as long as the district falls under one of the four models as designated in the Provider Notification of January 20, 2012.[44]
Q: If a student receives a service from a bundled CPT code, but does not receive all services in the bundled code, can schools bill for the service provided at a reduced rate?
A: Yes, schools can bill at a reduced rate for bundled CPT code services if the student does not receive the full complement of services covered with that code. Services are bundled under a CPT code because the services frequently occur together (i.e. combined speech sound production and language evaluation). However, the understanding is that while the services frequently occur in concert, this does not happen with every instance. Therefore, the opportunity exists for Service Providers to indicate the delivery of a bundled service at a reduced level, which generates billing at a reduced rate[45].
Q: If the school district does not meet the definition of a Speech and Hearing Agency relative to employment of an Audiologist, can the school district submit claims to MaineCare utilizing the “Independent Rate?”
A: Yes.[46]
[1] §109.02-9
[2] §109.02-1
[3] §109.04, §109.05.A.
[4] §1.02-4.E. DHHS response to comments to proposed regulation as published with the final rule on 11/28/11.
[5] §109.06
[6] §109.07
[7] §109.09-2
[8] §109.09-1.E., §109.09-2
[9] §109.07-1, §109.07-2
[10] §109.09-3
[11] Response to EDMS (MSB) from Kathy Bubar at DHHS on 12/8/2010
[12] §109.09-3.A.
[13] §109.09-3.B.
[14] Response to EDMS (MSB) from Kathy Bubar at DHHS on 12/8/2010
[15] §109.09-3.C.
[16] §109.07-1.A.
[17] §109.07-1.B., C.
[18] §109.07-1.D
[19] §109.07-1.E.
[20] §109.07-1.F.
[21] §109.07-1.G.
[22] §109.07-1.H.
[23] §109.02-2
[24] §109.07-1.I.
[25] §109.07-1.J.
[26] §109.07-1.K.
[27] §109.07-1.L.
[28] §109.07-1.M.
[29] §109.07-1.N.
[30] §109.08-1
[31] §109.07-1.O.
[32] §109.07-1.P., Q.
[33] §109.07-2.A.
[34] §109.07-2.B.
[35] §109.09-1.A.
[36] §109.09-1.B.
[37] §109.09-1.C.
[38] §109.09-1.D.
[39] §109.09-1.E.
[40] §109.09-1.F.
[41] §109.09-1.G.
[42] §109.09-1.H.
[43] §109.09-1.I §109.08-1, DHHS’ responses to comments during rulemaking, 8/26/10, indicated that “[s]ervices for children do not require prior authorization.”
[44] Provider Notification from Maine DHHS, 1/20/12
[45] ASHA Q & A http://www.asha.org/Practice/reimbursement/coding/New-CPT-Evaluation-Codes-for-SLPs/#7 in response to the bundled CPT codes effective 2/2014.
[46] 10-144 MaineCare Benefits Manual, Chapter III, §109: “The Independent Rate applies to organizations with either one or more Speech Language Pathologist or Audiologist.” “The Maine State Legislature directed MaineCare…to establish two such rates. (Agency and Independent) Currently, agencies that employ an audiologist are paid at a higher rate.” DHHS response to comment to proposed regulation as published with final rule on 11/28/11.