American Speech-Language-Hearing Association

Model Health Care Benefits

Ideal Health Plan Coverage for Audiology and Speech-Language Pathology Services

Hearing Benefits | Speech & Language Benefits | Resources

These model benefit plans for audiology and speech-language pathology services and devices were developed by ASHA to provide a document that offers guidance as to appropriate coverage levels. The model benefit plans include:

  • Audiology and speech-language pathology services that should be included;
  • The circumstances under which the services should be covered;
  • Recommendations regarding appropriate coverage levels; and
  • Recommendations for device allowances (e.g., hearing aids, augmentative and alternative communication devices).

For a print-friendly version of this information, please view ASHA's Model Speech, Language, and Hearing Benefits [PDF]. For questions, please contact reimbursement@asha.org.

Model Hearing Benefits Plan

Services and Devices [ 1 ]

Coverage Level & Device Allowances

CPT and HCPCS Codes

Evaluation & Management: Medical Team Conferences, Telephone Assessment and Management, and Online Assessment and Management Covered in full for the pediatric and adult populations for all medical diagnoses that have an ICD-9-CM code. Evaluation & Management codes include, but are not limited to: 98966, 98967, 98968, 98969, 99366, 99368

Assessment: Audiological, Tinnitus, Vestibular and Balance, Central Auditory, Cochlear Implant, Hearing Assistive Technology Systems (HATS), Auditory Rehabilitation, Hearing Aid Assessment and Fitting

Covered in full for the pediatric and adult populations for all medical diagnoses that have an ICD-9-CM code.

Assessment codes include, but are not limited to: 92540 through 92548, 92550, 92552 through 92568, 92570 through 92596, 92601 through 92604, 92620, 92621, 92625, 92626, 92627, 92640, 92700, 95920, 95925, 95930, 95934, 95936, 95937, V5008, V5010, V5011, V5014, V5020

Treatment: Audiologic (Aural) Rehabilitation/Habilitation, Vestibular and Balance, Auditory Processing, Cerumen Management, Canalith Repositioning

Covered in full for the pediatric and adult populations for all medical diagnoses that have an ICD-9-CM code as long as measurable and positive functional change is noted in a reasonable time period. [ 2 ]

Treatment codes include, but are not limited to: 92507, 92630, 92633, 95992, 69210

Devices: Hearing Aid Devices, HATS, Cochlear Implants and Accessories

  • $2000 hearing aid or HATS allowance per ear every 2 years
  • Replacement earmolds covered in full up to four times per year for children 7 years of age or under
  • $2000 cochlear implant speech processor allowance every 5 years
  • A HATS for use specifically with a cochlear implant covered in full once every 5 years

Device codes include, but are not limited to: V5030 through V5265, V5267 through V5269, V5273, V5275, L8619, L7510

[1] Services and Devices should be provided by an ASHA Certified and, where applicable, state licensed audiologist.

[2] If a limit on the number of sessions is established, the audiologist should be given the flexibility to determine the frequency and length of the sessions as well as the duration of treatment.

Model Speech and Language Benefit Plan

Services and Devices [ 1 ]

Coverage Level & Device Allowances

CPT and HCPCS Codes

Evaluation & Management: Medical Team Conferences Covered in full for the pediatric and adult populations for all medical diagnoses that have an ICD-9-CM code. Evaluation & Management codes include, but are not limited to: 98966, 98967, 98968, 98969, 99366, 99368

Assessment: Speech, Language, Voice, Stuttering, Communication, Cognitive, Auditory Processing, Auditory (Aural) Rehabilitation, Swallowing Function, Augmentative and Alternative Communication (AAC), Voice Prosthetic

Covered in full for the pediatric and adult populations for all medical diagnoses that have an ICD-9-CM code.

Assessment codes include, but are not limited to: 92511, 92520 through 92524, 92597, 92605, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 92626, 92627, 96105, 96110, 96111, 96125

Treatment: Speech, Language, Voice, Stuttering, Communication, Auditory Processing, Auditory (Aural) Rehabilitation/Habilitation, Cognitive Rehabilitation, Swallowing Function, AAC, Voice Prosthetic

Covered in full for the pediatric and adult populations for all medical diagnoses that have an ICD-9-CM code as long as measurable and positive functional change is noted in a reasonable time period. [ 2 ]

Treatment codes include, but are not limited to: 92507, 92508, 92526, 92606, 92609, 92618, 92630, 92633, 97110, 97112, 97150, 97530, 97532, 97533[ 3 ]

Devices: AAC and Prosthetic Devices & Accessories

Covered in full if recommended by an ASHA-certified, and/or licensed speech-language pathologist.

Device codes include, but are not limited to: E1902, E2500 through E2512, E2599, L8500 through L8515, V5336

[1] Services should be provided by an ASHA Certified and, where applicable, state licensed speech-language pathologist.

[2] If a limit on the number of sessions is established, the speech-language pathologist should be given the flexibility to determine the frequency and length of the sessions as well as the duration of treatment.

[3] The Centers for Medicare & Medicaid Services advises that use of physical medicine and rehabilitation codes (9700 series) are not appropriate for speech-language pathology or dysphagia services, except for 97532 and 97533. Some Medicare contractors and private payers may allow exceptions. Speech-language pathologists should discuss the appropriate use of the 9700 series of codes with the payer.

Resources

Current Procedural Terminology (CPT) Codes - The American Medical Association (AMA) developed CPT codes to provide a uniform language that will accurately designate medical, surgical, and diagnostic services, such as those provided by audiologists and speech-language pathologists.

Healthcare Common Procedure Coding System (HCPCS) - Level II HCPCS National Codes were developed by the Centers for Medicare and Medicaid Services (CMS) for reporting most medical services and supplies, including hearing aids and speech generating devices, provided to Medicare and Medicaid patients and by most private payers.

International Classification of Diseases, 9th Revision Clinical Modification (ICD-9-CM) - The intent of ICD-9-CM is to standardize disease and procedure classification throughout the United States. The ICD-9-CM is recommended for use in all clinical settings but is required for reporting diagnoses and diseases to all U.S. Public Health Service and Centers for Medicare and Medicaid Services (CMS) programs.

A copy of the CPT, HCPCS, and ICD-9-CM coding systems can be obtained from:

Ingenix Companies
P.O. Box 27116
Salt Lake City, UT 84127-0116
800-765-6588
801-982-4033 (fax)

American Medical Association Press
Order Department
P.O. Box 930876
Atlanta, GA 31193-0876
800-621-8335

Product Sales (Health Plan Coding and Claims Guide)
American Speech-Language-Hearing Association
2200 Research Boulevard #426
Rockville, MD 20850
888-498-6699
E-mail: productsales@asha.org

HCPCS codes can also be obtained from:

United States Government Printing Office
Superintendent of Documents
P.O. Box 371954
Pittsburgh, PA 15250-7954
202-512-1800

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