We definitely have challenges in getting specific-to-speech-related services paid for in early intervention (EI). And we should! Targeting specific speech sounds in isolation before the age of three years does NOT make sense on a developmental level—and this is exactly why insurance companies tend to question the claims. We know, however, that we need to address the needs of children who present with significant delays or disorders in language development, especially since we now understand that it is typically language that is the culprit when an infant or toddler is having difficulty communicating. We need to know, therefore, how to accurately bill for the child’s services as they relate to language.
The first order of business is to recognize that, in order to bill for services in the Commonwealth of Virginia, a service provider must submit a Current Procedural Terminology (CPT) code AND an International Classification of Diseases (ICD-9) code. The CPT is an indication of “what you are doing with the child”. The ICD-9 is the condition or diagnosis of the child for whom you are providing services.
The Basics of the CPT Code!
When considering CPT codes that relate to speech and language in EI, the system is fairly straight forward!
- The code that can and should be used in conjunction with a comprehensive communication assessment is SLP 92523. This code specifically covers “evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language)”.
- The code that can and should be used in conjunction with intervention (i.e. treatment) that addresses the communication and language skills of our infants and toddlers is SLP 92507. This code specifically covers “language/communication (SLP)” treatment.
Not too complicated, right?!
What About the ICD-9 Code?!?!?!
Unfortunately, when considering ICD-9 codes (also known as “diagnosis codes”), things get a BIT trickier. There are a few considerations, however, that should help you navigate the murky waters.
Private insurance reimbursement under 18 months of age:
- Private insurance companies will pay for speech-language pathology services for children who have been diagnosed with hearing loss/impairment, cleft lip/palate, or feeding as it relates to a medical condition such as laryngeal malacia or neurological insult (i.e. bleed, encephalitis) that has affected the child’s suck/swallow/breathe coordination. These are all fairly straight forward as the private insurance companies recognize that these are conditions that can be medically justified.
- Private insurance companies will NOT typically pay for language or communication services for infants or toddlers because they do not consider a developmental delay to be medically necessary. The Apollo Managed Care – Criteria Review Committee, who has set these guidelines, considers services that address communication and language of infants and toddlers as “addressing typical development” and will instead refer families for developmental services provided by infant educators to offer language/communication “stimulation.” Unfortunately, developmental services are not reimbursed by private insurance.
Medicaid reimbursement under 18 months of age:
Medicaid WILL pay for language-based and communication services for children under 18 months of age who have a diagnosed condition or who demonstrate a > 25% delay. If the infant or toddler is eligible for EI services, Medicaid will pay providers for the services!
And for those toddlers who are over 18 months of age?
While some private insurance companies will pay for SLPs to provide services to children with language/communication delays, they will still require medical justification to provide reimbursement. According to Kelly Hill, the Chair of the Virginia Interagency Coordinating Council and a Pediatric Physical Therapist in Warrenton, VA, service providers should avoid using generic statements like “delayed milestones”. She suggests using a code associated with a child’s medical condition in combination with a 315 (expressive language-related) code whenever applicable. Some examples include:
- 765.0 (prematurity) & 315.31 (expressive language disorder)
- 728.87 (muscle weakness) & 315.32 (mixed receptive-expressive language disorder)
- 758.0 (Down syndrome) & 315.31 (expressive language disorder)
There are always exceptions to the rule, and in the game of insurance and reimbursement, there are even exceptions to the exceptions! For example, Medicaid, Carefirst, Blue Cross/Blue Shield (BC/BS), and UnitedHealthCare will reimburse for services submitted under the following diagnosis codes: 781.3, any 315 codes (developmental & expressive language disorders), 783.4 (lack of normal physiological development), 783.42 (delayed milestones), 317-319 codes (intellectual disability), or 784.61 (apraxia). Aetna and Anthem (the statewide subsidiary of BC/BS) will no longer cover services when these very same codes are submitted. These two companies WILL occasionally pay for SLP services, however, when presented with the 784.5 code (speech disorder –not otherwise specified).
According to Ms. Hill, adhering to the following suggestions will support your claims for services that facilitate communication and language with our EI families:
- Document all diagnoses that the child has that are relevant to the services that you are providing! Include the Physician Authorization that also lists the diagnoses when submitting for reimbursement of services.
- Be sure that any progress notes support and substantiate the treatment code that is being used. SLP notes are often scrutinized by medical reviewers and tend to be flagged for not providing clear outcomes that are being addressed with services.
- Be consistent in your documentation in regard to the progress that a child is making toward his/her outcomes! Insurance companies want to see that your services are making a difference for the child with whom you are working.
As professionals, we recognize that we need to address the needs of children who present with significant delays or disorders in language and communication. We know that when we address the language development and difficulties that infants or toddlers present, the speech will follow. Now, we also have a little more knowledge about how to honestly and accurately bill for the child’s services as they relate to their language and communication skills.
What are some of the successes and challenges you’ve faced while managing reimbursement for speech therapy services?
Share your experiences and questions in the comments below!
If you missed either of Corey’s webinars, visit the Talks on Tuesdays 2015 recordings page on the VA Early Intervention Professional Development Center, or click below:
It’s Almost Never Apraxia: Understanding Appropriate Diagnoses of Speech in Early Intervention
Ditch the Animal Sounds: Writing Appropriate Outcomes that Lead to Effective Implementation
If you’d like to catch up on all of the posts in this series, visit:
What’s the Bottom Line Regarding Articulation in EI?!
Address the Language: The Speech Will Follow!
Ditch the Animal Sounds! – Who’s Ready for the Next Talks on Tuesday?!
This is an excellent summary for understanding the basics of coding/insurance issues for both new and experienced providers. There never seems to be an easy answer with insurance or the same answer twice. It is so important to at least know the foundational information ( the knowns) and then deal with the glitches ( the unknowns) as they come. So thanks for saying this OUT LOUD and AGAIN and AGAIN.
I do have a question….What is the correct order of listing the Diagnosis codes, the primary diagnosis first or the aspect that you the provider are targeting ? thanks!
Thank you for your response and for acknowledging how tough this information is…and can be…to deal with in the EI arena!
According to Kelly Hill, you may want to list multiple ICD-9 codes if the client has multiple diagnoses. Some diagnoses can stand alone (including Cleft palate, Swallowing disorder, Cerebral Palsy) when the diagnosis itself relates directly to the intervention/target.
In response to your specific question, in addition to the primary diagnoses, you will often also want to provide a diagnosis code for what you are treating specifically within your area of expertise (i.e. the aspect that you, the provider, are targeting). In this case, you will list your primary diagnosis first (e.g. Cleft palate, Down Syndrome, Cerebral Palsy, Encephalopathy). You will THEN list what aspect of that condition you are treating or targeting (e.g. weakness, disorganization, motor planning).
Always be sure that your documentation clearly links the diagnosis you are treating with your intervention and the family’s outcomes!
I hope that information is helpful. Thanks again for your feedback and your question, Colette!