American Speech-Language-Hearing Association

Medicare Speech-Generating Devices Information

Introduction

Pursuant to EB 36-2002, an ASHA Ad Hoc Speech-Generating Devices (SGD) Committee was formed and charged with the responsibility to a) pilot and refine an SGD reimbursement protocol; b) make recommendations for a variety of educational opportunities focusing on Medicare SGD coverage and documentation; c) develop a proposal for a mentoring program for speech-language pathologists (SLPs) who wish to become proficient in SGD assessment and treatment; and 4) make recommendations for articles to be published in The ASHA Leader and special interest division newsletters that highlight issues such as documentation for SGD assessments. Members of the committee were Deborah Parker Wolfenden (chair), Laura Ball, Katherine Hill, Joanne Lasker, Patricia Ourand, Celia Hooper (monitoring vice president for speech-language pathology practices, 2003-2005), Diane Paul (ex officio), and Silvia Quevedo (ex officio).

Committee members developed an information packet to assist SLPs in the SGD funding request process for Medicare coverage. The packet provides a brief summary of the key points regarding Medicare funding of SGDs and the roles and responsibilities of SLPs in submitting an SGD funding request. The packet contains an SLP Checklist to assist SLPs in completing an SGD funding request. Internet resources are provided for SLPs to access additional information, tools, and support in working through the SGD funding process. Also included are committee recommendations for resources and educational programs to be considered by the ASHA Executive Board for possible implementation. As in the provision of any clinical service, SLPs are guided by the ASHA Code of Ethics and SLP Scope of Practice.

Medicare Funding of SGDs

The ASHA SGD Committee developed a checklist to assist an SLP in the completion of a SGD funding Request. The SLP Checklist stems from the Regional Medical Review Policy (RMRP) (see Appendix A) issued by Medicare. The items on the checklist reflect the required components of the SLP report for funding by Medicare. SLPs should be aware that when any one of the items in the SLP Checklist is not properly submitted, the SGD funding request will be denied. The recommended SGD and accessories are covered if and when the coverage criteria have been met and medical necessity has been documented clearly in the formal report by the SLP.

SLPs are cautioned that the SLP Checklist reflects the SLP funding documentation requirements ONLY. The SLP Checklist does NOT specify or identify the elements required for a comprehensive augmentative and alternative communication (AAC) assessment. The SGD funding process is not a substitute for exemplary AAC clinical practice. All AAC assessments are individualized and differ according to diagnosis, the individual's abilities, communication needs, as well as other individual variables and environmental factors.

Prior to submitting a SGD funding request, patients must have a formal evaluation of their cognitive and communication abilities by an SLP. For a SGD to be covered by Medicare, it must:

  • be eligible for a defined Medicare benefit category,
  • be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,
  • meet all other applicable Medicare statutory and regulatory requirements.

In addition to the SLP report, other information NOT included in the RMRP is required for Medicare coverage. This required information is collected by the vendor/manufacturer and includes physician's prescription, UPIN, and co-payment check. The SLP may wish to assist in the process of gathering this information with the patient and vendor/manufacturer to expedite the completion of the documentation.

Also, the SLP should be aware that for an item to be considered for coverage and payment by Medicare, the vendor/manufacturer must be able to corroborate the information that has been submitted. Documentation such as the patient's medical records, physician's office records, records from other healthcare professionals, or test reports should be available and can be requested to show that the coverage criteria have been met.

This packet was prepared specific to Medicare funding. However, other funders of SGDs (e.g., Aetna, TriCAre, BCBS) may have adopted similar documentation requirements. Therefore, the information may be used as a reference for a variety of funding agencies.

Roles and Responsibilities of the SLP in the SGD Funding Request Process

In addition to satisfying the expectations of professional conduct outlined in the ASHA Code of Ethics and SLP Scope of Practice, the SLP must:

  • Complete an AAC assessment pursuant to the RMRP outline, recommend the most appropriate device, determine software and/or accessories needed, and determine whether the beneficiary can obtain the most appropriate device (determine whether Medicare covers the device, determine whether the manufacturer will accept Medicare assignment, determine whether the beneficiary can pay full purchase price if not covered or no assignment is accepted).
  • Prepare a written report and supporting information, addressing any required accessories in addition to the device.
  • Obtain a prescription from the treating physician that identifies the device and each accessory.
  • Contact the manufacturer/supplier to determine how claims will be processed and determine whether they will process the entire claim or whether software and accessories must be separate claims.
  • Assemble all paperwork plus necessary payment/co-payment from the beneficiary and forward it to the manufacturer/supplier.

SLP Checklist

Introduction

  1. For a speech generating device (SGD) to be covered by Medicare, it must:
    • be eligible for a defined Medicare benefit category
    • be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member
    • meet all other applicable Medicare statutory and regulatory requirements
  2. Prior to the delivery of the SGD, the patient has had a formal evaluation of their cognitive and communication abilities by a speech-language pathologist (SLP).
  1. The following SLP Checklist comes from the Regional Medical Review Policy (RMRP) ( see Appendix A) issued by Medicare that outlines the required components of the SLP report for funding by Medicare. If any one of the items in the SLP Checklist is not met, the SGD will be denied as not medically necessary. Accessories are covered if the SGD coverage criteria for the device are met and the medical necessity for each accessory is clearly documented in the formal evaluation by the SLP.
  1. Other information is required in addition to the SLP report but NOT included in the RMRP (e.g., physician's prescription, UPIN, co-payment check). This information is collected by the vendor/manufacturer and required for funding. SLPs may wish to assist with this process to aid the patient and potentially speed funding for the SGD. The SLP assessment protocol at the AAC-RERC Web site provides a guide for SLPs to conduct assessments and complete reports that address all of the points identified in the RMRP. The SLP Checklist may be used in conjunction with this document to aid the SLP.
  1. For an item to be considered for coverage and payment by Medicare, the information submitted by the supplier must be corroborated by documentation in the patient's medical records that Medicare coverage criteria have been met. The patient's medical records include the physician's office records, records from other health care professionals, or test reports. This documentation must be available upon request.
  1. Required elements of the SLP SGD Request Report, while specific to Medicare funding, are similar to and/or the same for some (but not all) funders of AAC devices (SGDs) (e.g., TriCare, BCBS, Aetna) and therefore may be used in a similar manner for a variety of funding agencies.
  1. The SLP Checklist reflects SLP funding documentation requirements ONLY. It does not specify the elements of a comprehensive AAC assessment. AAC assessments for SGDs are individualized and will differ depending upon etiology of the communication disorder, the individual's communication needs, the context, setting, access issues, and so on.
  1. The roles of the SLP include:
    • Completing an AAC assessment pursuant to the RMRP outline, recommending the most appropriate device, determining software and/or accessories needed, and determining whether the beneficiary can obtain the most appropriate device (determine whether Medicare covers the device, determine whether the manufacturer will accept Medicare assignment, determine whether the beneficiary can pay full purchase price if not covered, or no assignment is accepted).
    • Preparing a written report and supporting information, addressing any required accessories in addition to the device.
    • Seeking a prescription from the treating physician that identifies the device and each accessory.
    • Contacting the manufacturer/supplier to determine how claims will be processed and whether they will process the entire claim or whether software and accessories must be separate claims.
    • Assembling all paperwork plus necessary payment/co-payment from the beneficiary and forwarding it to the manufacturer/supplier.

Instructions for Use

Respond to each of the questions posed in the following grid to indicate whether the SGD funding report contains all of the items to ensure coverage and payment by Medicare. Check "yes" when you have completed or identified the element in the funding report prior to forwarding the request to the manufacturer/vendor.

Include patient information including name, date of birth, and medical diagnosis with date of onset.

The following components are identified by the RMRP as "reasonable and necessary" for Medicare funding.

  1. Does the SGD Funding report include current communication impairment, specifically addressing:
    • Communication diagnosis (apraxia, dysarthria, aphasia, and/or aphonia)
    • Severity level of the communication diagnosis (mild, moderate, or severe)
    • Language skills
    • Cognitive abilities
    • Anticipated course of impairment
    • That the medical condition is one resulting in a severe expressive speech disability
  2. Does the SGD Funding report include daily communication needs, specifically addressing:
    • Whether they could be met using other natural modes of communication
    • That speaking needs cannot be addressed using natural communication methods
    • That other forms of treatment have been considered and ruled out
  3. Does the SGD Funding report include functional communication goals, specifically addressing:
    • Expected goal achievement
    • Treatment options
    • A treatment plan that includes a training schedule for the selected device
    • That the patient's speech disability will benefit from the device ordered
  4. Does the SGD Funding report include cognitive and physical abilities, specifically addressing:
    • Demonstration that the patient possesses the cognitive abilities to use the selected device to communicate
    • Demonstration that the patient possesses the cognitive abilities to use the selected accessories to communicate
    • Demonstration that the patient possesses the physical abilities to use the selected device to communicate
    • Demonstration that the patient possesses the physical abilities to use the selected accessories to communicate
  5. Does the SGD Funding report include a financial relationship statement, specifically addressing:
    • That the SLP is not an employee of the supplier of the SGD
    • That the SLP does not have a financial relationship with the supplier of the SGD
  6. Does the SGD Funding report include a physician notification statement, specifically addressing:
    • That a copy of the SLP's written evaluation and recommendations have been forwarded to the patient's treating physician prior to ordering the device
  7. If an upgrade to a previously issued SGD is being requested, does the SGD Funding report include functional benefit, specifically addressing:
    • The functional benefit to the patient of the upgrade compared to the initial SGD

Appendix A

RMRP Coverage and Payment Rules

For any item to be covered by Medicare, it must:

  1. be eligible for a defined Medicare benefit category
  2. be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member
  3. meet all other applicable Medicare statutory and regulatory requirements

For the items addressed in this regional medical review policy, "reasonable and necessary" is defined by the following coverage and payment rules.

A speech-generating device (E2500 - E2511) is covered when all of the following criteria (1-7) are met. If one or more of the SGD coverage criteria 1-7 is not met, the SGD will be denied as not medically necessary.

  1. Prior to the delivery of the SGD, the patient has had a formal evaluation of their cognitive and communication abilities by a speech-language pathologist (SLP). The formal, written evaluation must include, at a minimum, the following elements:
    • current communication impairment, including the type, severity, language skills, cognitive ability, and anticipated course of the impairment
    • an assessment of whether the individual's daily communication needs could be met using other natural modes of communication
    • a description of the functional communication goals expected to be achieved and treatment options
    • rationale for selection of a specific device and any accessories
    • demonstration that the patient possesses a treatment plan that includes a training schedule for the selected device
    • the cognitive and physical abilities to effectively use the selected device and any accessories to communicate
    • for a subsequent upgrade to a previously issued SGD, information regarding the functional benefit to the patient of the upgrade compared to the initially provided SGD
  2. The patient's medical condition is one resulting in a severe expressive speech impairment
  3. The patient's speaking needs cannot be met using natural communication methods
  4. Other forms of treatment have been considered and ruled out
  5. The patient's speech impairment will benefit from the device ordered
  6. A copy of the SLP's written evaluation and recommendation has been forwarded to the patient's treating physician prior to ordering the device
  7. The SLP performing the patient evaluation may not be an employee of or have a financial relationship with the supplier of the SGD

Codes E2500 - E2510 and code E2511 perform the same essential function-speech generation. Therefore, claims for more than one SGD will be denied as not medically necessary. Laptop computers, desktop computers, PDAs, or other devices that are not dedicated SGDs are not covered because they do not meet the definition of durable medical equipment (DME). Software (E2511) that enables a laptop computer, desktop computer, or PDA to function as an SGD is covered as an SGD; however, installation of the program or technical support are not separately reimbursable.

Accessories

Accessories (E2512 and E2599) for E2500 - E2511 are covered if the basic coverage criteria (1-7) for the base device are met and the medical necessity for each accessory is clearly documented in the formal evaluation by the SLP.

SGD Recommendations

  1. Recommendations for a variety of educational opportunities focusing on SGD coverage and documentation.
    1. Develop ASHA-sponsored educational opportunities that might include the following:
      1. Offer ASHA convention presentations that focus on funding and documentation.
      2. Consult with the AAC convention program committee and SIG 12 regarding invited session(s) for the 2004 ASHA convention
      3. Conduct the scheduled ASHA telephone seminar scheduled for March 2004 and develop additional telephone seminars on the topic in future years.
      4. Consult with ASHA's Professional Development Team regarding putting together ("bundling") a package of existing ASHA products related to AAC/SGD funding for adults.
      5. Consult with SIG 12 to suggest that topics such as Medicare funding be the focus for a future SIG 12 leadership conference.
    2. Develop other continuing education opportunities on Medicare funding of SGD's.
    3. Develop distance learning programs/telemedicine that include funding of SGDs.
    4. Conduct a search and appraisal of organizations with similar missions and approved funding streams to support the development of educational resources and tools (e.g., RESNA, ALSA, MDA, AAC Institute). Reciprocal Web site links can be requested to these resources.
    5. Collaborate with other agencies and existing committees and groups focusing on SGD funding.
    6. Develop materials for course syllabi/curricula that include funding of SGDs.
    7. Create scenarios (e.g., written vignettes, videos, flash presentations) so that SLP's can practice SGD funding procedures for continuing education.
    8. Write a resolution to update the ASHA family of documents on AAC so that they include information about Medicare funding procedures.
    9. Create online resources that offer more extensive information about AAC assessment. For example, consider the document(s) created by this committee (Appendix #).
    10. Develop materials based on the variety of Medicare eligible populations; consider variety of ages, diagnoses, environments, and cultures for customizing this information.
    11. Create consumer-ready, consumer-focused information (e.g., a Public Service Announcement) to educate families and consumers regarding Medicare funding.
  1. Develop a proposal for an ASHA mentoring program for SLPs who wish to become proficient in SGD assessment and treatment.
    1. Develop a mentoring program for SLPs who wish to become proficient in SGD assessment and treatment, as well as funding. Consider as potential partners, the ASHA MR/DD committee, Gerontology (SIG 15), Administration and Supervision (SIG 11), Neurophysiology & Neurogenic Speech & Language Disorders (SIG 2), National Joint Committee for the Communication Needs of Persons With Severe Disabilities, and Augmentative and Alternative Communication (SIG 12).
    2. Develop criteria for mentors based on demonstrated performance- related AAC clinical practice and SGD funding.
    3. Explore alternative funding options for the mentor. (e.g., NIDRR funding opportunities, ED grants/personnel preparation grants, private foundations). Consider honoraria for mentors.
    4. Develop preservice and inservice educational tracks for the mentoring program.
    5. Pair AAC mentors with university programs, perhaps via distance learning techniques.
      1. Develop a curriculum/script for mentoring program. See student minority leadership program and AAC competencies for models of mentoring programs.
      2. Provide ASHA continuing education units and/or financial compensation for mentors participating in mentorship programs.
  1. Make recommendations for articles to be published in The ASHA Leader and Special Interest Group newsletters that highlight issues such as documentation with SGD assessment.
    1. Solicit articles highlighting SGD funding and documentation.
    2. Expand the list of resources cited above to include: NSSLHA journal, NBASLH publications.
    3. Identify ASHA members to write articles highlighting SGD funding and documentation for non-ASHA publications (e.g., state associations, RESNA, Closing the Gap, Advance).
    4. Solicit articles focusing on the following topics:
      1. AAC assessments: Beyond the funding request.
      2. SLP's responsibilities in SGD funding requests.
      3. Resources to support meeting Medicare requirements.
      4. Comparison of funding request section requirements and AAC assessment procedures.
      5. Integration of RMRP requirements into an AAC assessment report.
      6. Case studies involving Medicare funding.
      7. Retrospective analysis of funding process and timeliness.
      8. Medicare coding for services and SGDs
      9. Ethical responsibilities when completing AAC assessment/interventions and funding requests.
      10. Acceptance rates with SGDs.
  2. Implementation
    1. Complete a cost benefit analysis for all suggested programs.
    2. Appoint a person or persons to be responsible for implementation of these recommendations.

Medicare SGD Funding—Internet Resources

American Speech-Language-Hearing Association (ASHA)

AAC Institute

AAC Rehabilitation Engineering Research Center on Communication Enhancement (AAC-RERC)

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