1.0 CPT PROCEDURE CODES
92507, 92508, 92521 - 92524, 92610,
92611, 92630 - 92633
2.0 DESCRIPTION
Speech-language pathology services
that provide evaluation, treatment, habilitation, and rehabilitation
of communication disorders resulting from congenital anomalies,
disease, injury, hearing loss, pervasive developmental disorders
or a therapeutic process, or other condition, such as pragmatic language
impairment, that prevents or diminishes an individual’s ability
to communicate.
3.0 POLICY
3.1 Speech-language
pathology services prescribed and supervised by a physician, certified Physician
Assistant (PA) working under the supervision of a physician, or
certified Nurse Practitioner (NP) may be cost-shared.
3.2 Speech-language pathology services
to improve, restore, or maintain function, or to minimize or prevent
deterioration of function of a patient when prescribed by a physician,
certified PA working under the supervision of a physician, or certified
NP is covered in accordance with the rehabilitative therapy provisions
found in
Section 18.1.
3.3 Videofluoroscopy evaluation
in speech pathology is covered when medically necessary.
4.0 EXCLUSIONS
4.1 Services
provided to address speech, language, or communication disorders
resulting from occupational or educational deficits.
4.2 For beneficiaries under the
age of three, services and items provided in accordance with the beneficiary’s
Individualized Family Service Plan (IFSP) as required by Part C
of the Individuals with Disabilities Education Act (IDEA), and which
are otherwise allowable under the TRICARE Basic Program or the Extended
Care Health Option (ECHO) but determined not to be medically or
psychologically necessary, are excluded.
4.3 For beneficiaries
ages three to 21 who are receiving special education services from
a public educational agency, cost-sharing of outpatient speech services
that are required by the IDEA and which are indicated in the beneficiary’s
Individualized Education Program (IEP), may not be cost-shared except
when the intensity or timeliness of speech services as proposed
by the educational agency are not appropriate medical care.
4.4 Myofunctional or tongue thrust
therapy.
4.5 Maintenance therapy that does
not require a skilled level after a therapy program has been designed
(see
Section 18.1).
4.6 Speech therapists (speech pathologists)
are not authorized to bill using Evaluation and Management (E/M)
codes listed in the Physicians’ Current
Procedural Terminology (CPT).
4.7 Sensory Integration
Therapy (SIT) (CPT 97533) is unproven.SIT services
are not payable separately or when billed in conjunction with other
therapies. For example: SIT services provided during an otherwise
covered multidisciplinary therapeutic intervention or service; during
physical therapy, occupational therapy, or speech therapy; or as
a component of cognitive rehabilitation, are services for which
TRICARE bundles payment into the payment for other related services.