American Speech-Language-Hearing Association

Medicare Speech-Generating Devices Information Packet: SLP Checklist

Medicare Speech-Generating Devices Information Packet

Introduction | Instructions for Use | Appendix A

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.

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