It is hard to believe but it is almost May!  The final Talk of the two-part series, entitled “Ditch the Animal Sounds: Writing Appropriate Outcomes that Lead to Effective Implementation,” will be presented live on May 5^th!  In anticipation of the upcoming webinar, I am excited to share with you just a few of the key points that I will be presenting in the session

In my first two blog posts on articulation and addressing language development, I talked specifically about how important it is to remember that functional services should be based on the appropriate diagnoses of the young children with whom we work.  These kids DO need services—but when we are diagnosing appropriately and accurately, our services for infants and toddlers will typically be based on a diagnosis of a language disorder versus a speech sound disorder. With that in mind, we should, therefore, be providing services that focus on language development rather than on speech sound development…or better yet, we should be using best practices by coaching families to facilitate speech sound development within (rather than separate from) activities that target functional communication by and with the child!

Sounds easy enough to do, right?!

Outcomes – Focusing on What’s FUNCTIONAL

When we are working with a child who is really struggling to get his basic needs or wants met because he does not have the LANGUAGE, focusing specifically on and teaching a child to produce a bunch of animal sounds is really not a FUNCTIONAL choice.  So a child learns to ‘moo’ or ‘meow.’  Does that really help him get a drink of milk or call his mom when he needs her?!  Those sounds can be fun…and for most children, they really do grab their attention and make them smile…if not even eventually imitate.  But what about those children for whom language is a challenge?  When writing outcomes, animal sounds, environmental sounds, and silly sounds are just not functional.

…Think about this for just a minute…

Is the family’s goal for this child really to produce animal sounds or to imitate the sound of an airplane or a car engine?!

When we work with young children who are struggling with language development, we recognize that they need to be able to produce sounds in order to produce words.  Those sounds, however, need to be addressed within functional, natural contexts.  Addressing a child’s ability to obtain needs and wants by learning how to label desired objects or to make a verbal request…THESE are functional outcomes.  In order to request a drink, or to ask for more, or to label the boots that a little boy wants to wear to play in the snow, he needs to be able to produce an approximation of the words “milk”…and “more”…and “boots”.  While the outcome itself is not to produce the /m/ or the /b/ sounds specifically, the production of these sounds can and should certainly be EMBEDDED into the intervention itself.

What should these outcomes look like?  Need examples of functional outcomes for a toddler who presents with an expressive language delay or disorder?  How can or should we select target words to include within a child’s outcomes? Join me for the May 5^th Talk on Tuesday to answer these and other questions you may have about writing outcomes!

Intervention: What Does It Look Like?!

When I work with families, I always keep a few key considerations in mind…and these considerations—or TIPS—tend to form the foundation by which I coach the parents and the caregivers on ways that they can embed speech sound development into their everyday activities and routines.  Each of these tips is intended to help families embed speech sounds into play-based or routines-based, language rich activities while they are engaged with their children. By now, we are all aware of the fact that children need to be able to make sense of stimuli in order to learn from it.  In order for a child to process information, it needs to be presented within a normal, naturally occurring event or opportunity in his or her own environment.  Using flashcards to teach sounds or words, or creating superficial teaching opportunities like pushing a child to imitate sounds, is not going to work.  Infants and toddlers truly do NOT learn, and ultimately develop, speech or language through artificial methods.

Instead, their verbalizations—their LANGUAGE–should be based on models that we have provided within the natural routines and activities—these are the opportunities that will have meaning, and positively impact learning, for, a child. Young children will naturally imitate the speech sounds that are embedded within the language that they can, and want, and need to use within their everyday lives–even those who are struggling with their language.  They do NOT, however, tend to imitate sounds that do not have a place within naturally occurring, everyday activities and routines—and those are the opportunities in which we can encourage and coach families to embed sounds in language.

So…anyone want to know what these fancy tips are?  Again, be sure to tune in to the May 5^th Talk on Tuesday to learn more about how to work with families and coach caregivers to embed speech sound development into everyday routines and activities. 

Do you have some tried-and-true strategies that you use to embed speech sounds into natural learning opportunities with the families with whom you work? 

Share your ideas here!

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!

ICD-10 Codes and Insurance Reimbursement in EI: The Fun Stuff?!?

The post Ditch the Animal Sounds! – Who’s Ready for the Next Talks on Tuesday?! appeared first on Early Intervention Strategies for Success.

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)

The Glitches

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).

Now What?!

According to Ms. Hill, adhering to the following suggestions will support your claims for services that facilitate communication and language with our EI families:

1. 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.
2. 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.
3. 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?!

The post ICD-10 Codes and Insurance Reimbursement in EI: The Fun Stuff?!? appeared first on Early Intervention Strategies for Success.

Joey is 25 months old.  He was referred to his local early intervention intake coordinator by his parents secondary to their concerns about his intelligibility and inability to effectively communicate his needs or wants.  They reported that he uses approximately 15 words but “talks in such a garbled manner” that both parents and Joey’s older siblings become frustrated when they don’t know what he is saying or requesting. When asked to describe Joey’s speech, his father noted that it sounds like: “babble-babble-babble-mama-babble-babble-babble, as if he knows he should be talking in longer sentences but he doesn’t have the vocabulary yet to form the actual sentence”.  His mother added that he sometimes sounds like he is humming around his words: “mmmmmmm-ball-mmmmm”.  Joey loves playing with balls.  His family often takes an extra ball with them to Joey’s brother’s soccer practice.  While his brother practices, Joey and his Dad kick the ball. According to Joey’s parents, they find his speech particularly frustrating before meal times; they noted that he loves to help them choose and prepare food for snacktime every day, but that they often don’t understand which foods and/or drinks he is requesting or suggesting.

What to Do? What to Do?!

We see this quite often, don’t we?!  Parents will often come to us with concerns about their child’s intelligibility and “speech skills” because they have difficulty understanding the messages that their children are trying their hardest to convey.  As a speech-language pathologist (SLP), my first goal with this child would be to conduct a comprehensive communication assessment by collecting a speech and language sample.

Within this play-based sample, I would listen for those three speech-related red flags that I presented in the March Talks on Tuesdays webinar and in my previous blog post: 1) initial sound deletions; 2) distortion or consistent difficulty with vowels; and 3) deletion of LOTS of sounds—the child uses only one or two consonant sounds. Ultimately, however, above and beyond my observations regarding Joey’s speech productions, I would assess whether he is using the language skills that are developmentally expected for his age.

Typical Language Development vs. Expressive Language Delay or Disorder

Keep in mind that we expect children to have a vocabulary of at least 15-20 words by 18 months, although typically developing children often have more than 50 words and are beginning to string simple, repetitive 2 word phrases together (e.g. more drink, my juice) by this age.  By 24 months, we expect a children who are typically developing to use AT LEAST 50 words and to combine lots of different phrases. Between 18-24 months, children may still use some jargon to expand their sentence length and to attempt to provide “more information” in their messages.  If you have a child who is 20-24 months and using a lot of jargon and not a lot of words, however, you are probably looking at a child who has an expressive language disorder.

Is It a Language Disorder or a Speech-Related Disorder?

Toddlers who are extremely difficult to understand are often still using a lot of jargon when they speak because they lack vocabulary…or have difficulty with grammatical markers… or struggle to put words together into phrases.  All of these are skills that are expected by two years of age.  We typically expect that jargon (which can be defined as “babbling with intent”) will begin to fade at about 18 months and completely dissipate by 24 months.  If a toddler has an expressive language delay or disorder, his intelligibility will be affected as he will often continue to use a lot of jargon in lieu of words.  Instead of recognizing that the jargon is a substitute for real words or grammar that SHOULD have developed, we often misinterpret the jargon to be speech sound production errors.

In this scenario, Joey’s desire to communicate is there…his speech is continuing to develop…his language skills are not. Therefore, most toddlers, including Joey, who are difficult to understand will be diagnosed with a language disorder—not a speech-related disorder!  It is the language (or lack thereof) that is most likely having the greatest impact on this child’s intelligibility.  Unless Joey presents with any of the speech-related red flags, his speech will most likely continue to develop as his language skills are addressed in early intervention!

Why Not Provide Traditional Articulation Therapy Anyway?

Early speech and language skills are acquired and used primarily for communicating during every day, natural social interactions. Traditional articulation therapy focuses on the repetition and drilling of target sounds…there is nothing natural about this process. Early intervention is intended to be embedded into families’ every day, natural activities and routines to ensure that children are processing the information that they are learning in order to utilize these new skills within their own environment—this is known as authentic learning.  Targeting articulation directly and drilling toddlers to produce speech sounds is the furthest thing from “natural” that there is!

Optimal early communication intervention services are provided in natural environments, which offer realistic and authentic learning experiences for the child and promote successful communication with the caregivers. Authentic learning can maximize children’s acquisition of functional communication skills and promote generalization of newly mastered behaviors to natural, everyday contexts. In order for a child to process information, it needs to be presented within a normal, naturally occurring event or opportunity in his or her own environment.  Using flashcards to teach sounds or words, or creating superficial teaching opportunities like pushing the child to imitate specific sounds in isolation (e.g. “say /ba/”), is not going to work.  Infants and toddlers truly do not learn speech or language through artificial methods.  For most children, when functional language and communication needs are addressed within the natural environment, speech will develop as well (ASHA, 2008)!

What Would This Look Like for Joey and his Family?

My first suggestion for Joey’s parents is to support and encourage him to continue to produce the sounds and words that he IS producing within the routines that he most enjoys.  If he makes ANY sounds, imitate those. If he uses any word approximations or words, repeat them back to him! Continue to imitate his sounds and words…and then expand on them a bit.  If Joey says “babble-babble -nana-babble-babble-juice” while choosing foods for his snack, repeat his word approximations and words back to him:  “Banana!  Juice!”  Then, I would coach his parents to expand on his verbalizations: “You want bananas and juice for snack today! Let’s have bananas and juice!”  Let him know that what he is attempting to say has been heard and IS important.  I would encourage his parents to provide him with articulate models of his words and to provide a model of a complete sentence in order to facilitate Joey’s expansion of his message.

What other authentic learning opportunities might you use to facilitate Joey’s expressive language development during snack time and ball play during his brother’s soccer practice?

What are some other ways in which you can help Joey’s family incorporate naturally occurring opportunities to embed speech sound development into these experiences along the way?

Reference

American Speech-Language-Hearing Association. (2008). Roles and responsibilities of speech-language pathologists in early intervention: guidelines [Guidelines]. Available from www.asha.org/policy.

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?!

ICD-10 Codes and Insurance Reimbursement: The Fun Stuff?!?

Ditch the Animal Sounds! – Who’s Ready for the Next Talks on Tuesday?!

The post Address the Language: The Speech will Follow! appeared first on Early Intervention Strategies for Success.

On March 3, 2015, I was honored to present a Talk on Tuesday (ToT) webinar entitled, It’s Almost Never Apraxia: Understanding Appropriate Diagnoses of Speech in Early Intervention, that addressed appropriate diagnoses of speech sound disorders in infants and toddlers.  The participants had some great questions and we wanted to ensure that the conversation continues…so here I am!  My March ToT was just Part 1 of 2. The second half will be presented on May 5^th and will focus on outcomes and intervention in regard to speech sound development!  But in the meantime, it seems as though a big misconception from my March Talk is that I am advocating for fewer services for infants and toddlers…this is not the message that I intended to convey and I am hoping to begin this blog series by clearing that up!

First, let’s begin with a quick review of the facts:

When Should We Become Concerned about the Development of Articulation?

Typically, a speech-language pathologist (SLP) will diagnose an articulation disorder if a child is demonstrating a delay of at least 6-12 months in regard to the production of certain sounds, based on the age at which mastery of the sounds is expected.  To put this in perspective, because the /k/ and /g/ sounds are expected to be mastered by the age of 4 years, a child should not be differentially diagnosed with an articulation disorder characterized by errors of these sounds…until the child is at least 4 and a half years old.

What about Phonology?!

A child’s speech development is not just about his or her articulation skills.  When SLPs are assessing a child’s speech, we are also looking at the sound patterns—the phonological processes–that a child is, or is not, producing.  As you can imagine—and as most of you have experienced!—in addition to developmental articulation errors, these processes often wreak havoc on our ability to understand what children are saying.  And yet…should we be concerned when working with children under the age of 3 years old?  Well…not really.  A phonological delay or disorder refers to when a child continues to simplify his or her speech by using these phonological processes well beyond the typical age expected.

Unless we consistently observe a toddler demonstrating the following red flags:

• initial sound deletions;
• distortion or consistent difficulty with vowels;
• deletion of LOTS of sounds—the child uses only one or two consonant sounds…

…we should not diagnose an articulation or phonological disorder prior to the age of 3 years. Again, since most of the processes that we monitor are expected to be present in a child’s verbalizations until the age of 3 or older, we really just want to monitor the patterns in a child’s words and phrases until they are 3 years old.

And What about the Role of Intelligibility? 

Well, again, since we now know that children are going to be difficult to understand prior to the age of 4 years, an SLP will determine just HOW unintelligible a child is at a given point in time.  If a child is less than 25% intelligible by 2 years of age or less than 50% intelligible by 3 years old, we should be concerned.  It is then the role of the SLP to determine what the roadblock to the child’s intelligibility really is.  Otherwise, it’s important to keep in mind that a 2 or 3 year old IS going to be difficult to understand…often!

Now that We’ve Reviewed the Expectations, Let’s Address the Misconception!

I am certainly not advocating for FEWER services for infants and toddlers…instead, I am advocating for FUNCTIONAL services for our children and their families!

Stronger services = functional services!

Functional services will be based on appropriate diagnoses of the young children with whom we work.  These kids DO need services—but when we are diagnosing appropriately and accurately, our services for infants and toddlers will be based on the diagnosis of a language disorder versus a speech sound disorder. We should, therefore, be providing services that FOCUS on language development rather than on speech sound development…or better yet, we should be providing best practices by coaching families to facilitate speech sound development within (rather than separate from) outcomes and activities that target functional communication by and with the child!

If you did not have the opportunity to participate in the live March 2015 ToT webinar, I invite you watch it now!  I would love to hear what you think about the information that I presented and where we should go from here!

What strategies do you use to facilitate speech sound development within everyday functional activities?

Share your ideas 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:

Address the Language: The Speech Will Follow!

ICD-10 Codes and Insurance Reimbursement in EI: The Fun Stuff?!?

Ditch the Animal Sounds! – Who’s Ready for the Next Talks on Tuesday?!

The post What’s the Bottom Line Regarding Articulation in EI?! appeared first on Early Intervention Strategies for Success.