New diagnosis codes for cognitive communication deficits have been available for almost two years, but not all health plans—including Medicare—recognize them or allow speech-language pathologists providing cognitive rehabilitation services to use them.
The new codes, which became effective Oct. 1, 2010, were introduced into the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) in response to efforts by the U.S. Departments of Defense and Veterans Affairs to improve the coding of intracranial injuries and associated symptoms. The new ICD-9-CM diagnostic subcategory [PDF] for signs and symptoms involving cognition (799.5x) captures a spectrum of cognitive disorders.
Private and federal health plans are inconsistently incorporating the 799-series codes. Most Medicare administrative contractors (MACs) recognize at least one of the codes (see chart [PDF]). The Medicare scope of coverage for speech-language pathology includes cognitive rehabilitation treatment, but the regional MACs independently specify covered diagnosis and procedure codes in their local coverage determinations.
In communication with all MACs, ASHA requested that they include 799.52 (cognitive communication deficit) in their local coverage determinations, and continues to advocate for their use.
TRICARE, the health insurance program for service members and their families, does not cover cognitive rehabilitation—although individual speech-language services are covered. An Institute of Medicine study on cognitive rehabilitation—commissioned by the U.S. Department of Defense, which is looking for ways to deal with the rising incidence of TBI among service members returning from the conflicts in Iraq and Afghanistan—was deemed not sufficiently conclusive (The ASHA Leader, Dec. 20, 2011).
SLPs can use diagnosis code 784.69 (other symbolic dysfunction) to capture neurological language impairments, including cognitive communication problems, if the patient's MAC is not using the 799-series codes (every MAC includes 784.69 in its speech-language pathology scope of coverage). If the MAC also allows 799.52, SLPs should use only one code to describe cognitive communication deficits (one or the other, but not both). If the cognitive disorder is caused by a stroke, use 438.0 (cognitive deficits: late effects of cerebrovascular disease). One MAC (Novitas) specifies that an additional code, besides 438.0, should be included "to clarify the reason/diagnosis for SLP services."
Although the 799 codes were developed specifically to focus on TBI and associated symptoms, the codes might be used for a range of disorders. To clarify their appropriate use, ASHA is working with the ICD-9-CM Coordination and Maintenance Committee of the National Center for Health Statistics to provide guidance on how speech-language pathologists may use them. The committee is working with the American Hospital Association (AHA)—the U.S. clearinghouse for issues related to the use of ICD-9 codes—which is expected to publish guidance in the AHA Coding Clinic shortly.
The Value of Cognitive Rehabilitation
Medicare recognizes the role of speech-language pathologists in providing cognitive rehabilitation in the Center for Medicare and Medicaid Services Program Memorandum AB-00-14 (March 2000). Additionally, outcomes data, systematic literature reviews, and research all point to the efficacy of cognitive rehabilitation.
However, Medicare requires that rehabilitative services result in significant functional progress in a reasonable period of time—that is, the patient functions with a higher level of independence after two to four weeks of treatment.
Data from ASHA's National Outcomes Measurement System show that most patients with TBI who received speech-language pathology services made at least one level of progress on the functional communication measures in four key areas of cognitive-communication skills: attention, memory, pragmatics, and problem-solving. Patients with cerebrovascular disease (right-hemisphere) who received speech-language treatment also improved in attention, memory, pragmatics, and problem-solving.
An Archives of Physical Medicine and Rehabilitation article, "Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002" (August 2005), reports that there is "substantial evidence to support cognitive-linguistic therapies for people with language deficits after left hemisphere strokes," as well as for people with TBI.