Medicare Benefit Policy Manual

CMS Issues Changes Impacting Delivery of Outpatient Speech-Language Pathology Services

On May 6, 2005, the Centers for Medicare and Medicaid Services (CMS) issued changes to its Benefit Policy Manual which states that a physician order is not required for speech-language pathology services to be provided to a Medicare beneficiary. Rather, Medicare payment will be contingent on the physician's certification of the plan of care. This change does not allow for direct access to therapy services, as Medicare law requires the patient to be under the care of a physician. Moreover, it does not allow speech-language pathologists to bill Medicare as private practitioners.

As part of the changes, CMS outlines specific requirements that need to be met in order to receive payment for outpatient rehabilitation services:

• The services are medically necessary;
• A plan of care has been established by either a speech-language pathologist or the physician; and
• Services were provided while the individual is or was under the care of a physician.

CMS cautions that although an order is not required for payment, documentation of an order is prudent because it confirms that the physician is involved in the care of the beneficiary. Medicare will continue to require a physician review of the plan of care every thirty days, however, CMS has waived the necessity for the beneficiary to be seen by the physician in order certify the treatment plan.

In rewriting its coverage criteria for dysphagia services, CMS recognizes that fixed, mobile, or portable equipment may be used in the modified barium swallow (MBS) examination. CMS also addressed concerns raised by ASHA that, under current requirements, individuals who were not competent could provide dysphagia evaluation and treatment services. In the revisions to the policy manual, CMS includes a list of competencies that the practitioner must meet in order to be reimbursed for providing dysphagia services.

ASHA provided extensive comments to CMS on the draft revisions to Medicare's coverage policies for outpatient speech-language pathology services, and applauds CMS staff for their continued interest in ensuring that all rehabilitation services are provided in an efficient and effective manner.

The CMS change request can be found on the agency's Web site at http://www.cms.hhs.gov/Transmittals/downloads/R36BP.pdf. For additional information, please contact Neela Swanson, ASHA's Health Care Financing Information Coordinator, at nswanson@asha.org or by phone at 800-498-2071, ext. 4387.

Additional Resources

ASHA comparison table:
Relevant Changes in Medicare Outpatient Coverage and Claims Procedures [PDF].

CMS PowerPoint presentation:
Medicare Benefit Policy Manual - Therapy Policies http://www.cms.hhs.gov/medlearn/therapy/