North Dakota Medicaid Coding and Payment Policy Is Changing

North Dakota Medicaid has updated its coverage policies for speech therapy services, including changes to its coding and billing practices for speech, occupational, and physical therapies (ST/OT/PT) for Medicaid beneficiaries. These changes were first announced on December 31, 2025 and updated on January 28. Changes went into effect on February 1.

There are two main changes for speech-language pathology services:

• Shifting untimed visits to timed unit-based services for Medicaid beneficiaries over age 21; and
• Changing the underlying minimum times associated with the use of CPT® code 92507 for all Medicaid beneficiaries.

Shifting to Per-Unit Limits for Adults

In order to provide billing consistency across services for adults, North Dakota Medicaid is moving from a per-visit limit to a per-unit limit for ST/OT/PT.

• ST – 30 visits –> 30 units
• OT – 30 visits –> 60 units
• PT – 30 visits –> 60 units

If patients have additional medical necessity for services, providers can seek further service authorization as they were previously able to do.

Changing Minimum Times for CPT Code 92507 for All Medicaid Beneficiaries

CPT code 92507 describes the individual treatment of speech, language, voice, communication, and/or auditory processing disorders. Though CPT code 92507 does not include a specific time designation in its descriptor and is therefore classified as an untimed code, it was originally established through the American Medical Association’s CPT and Relative Value Scale Update Committee (RUC) valuation process with an implicit time component.

Even in the absence of an explicit time requirement, the reimbursement and relative value assigned to CPT code 92507 reflect the typical underlying time and resources necessary to provide the service. Since its last valuation in 2010, CPT code 92507 has had an underlying total time of 60 minutes and has been valued accordingly. This total time reflects:

• 5 minutes of pre-service time (this time is included as part of the value of the code and cannot be counted toward time spent for billing purposes);
• 50 minutes of intra-service time (this is the face-to-face treatment time with the patient, which is counted toward time spent for billing purposes); and
• 5 minutes of immediate post-service time (this time is included as part of the value of the code and cannot be counted toward time spent for billing purposes).

Effective for dates of service on or after February 1, 2026, in North Dakota:

• When less than 35 minutes of face-to-face time is spent performing CPT 92507, modifier -52 (reduced service) must be appended to the claim line and will be reimbursed at 50% of the current fee schedule amount.
• When greater than 90 minutes of face-to-face time is spent performing CPT 92507, modifier -22 (increased service) must be appended to the claim line and will be reimbursed at 120% of the current fee schedule amount.

On January 28, 2026, North Dakota Medicaid posted an additional policy update to clarify that the upcoming changes to CPT code 92507 will apply to both pediatric patients under the age of 21 and adult beneficiaries. Providers will continue to be paid the same rate of $85 for services that satisfy the 35-minute minimum requirement.

Despite these new coding changes, North Dakota Medicaid reimbursement rates continue to be among the highest Medicaid reimbursement rates in the country.

The Bigger Picture

Several broader factors likely influenced North Dakota Medicaid’s decision to change the payment structure for CPT code 92507, including reduced funding streams, coding and billing patterns, and CPT coding principles. These challenges are not unique to North Dakota. Other state Medicaid programs are facing similar pressures as they reassess coding and coverage decisions.

Changes in Funding to State Medicaid Programs

On July 4, 2025, President Trump signed the One Big Beautiful Bill Act (OBBBA) into law. This law will cut almost $1 trillion from state Medicaid programs over the next 10 years. ASHA vigorously advocated against these changes to Medicaid. ASHA continues to support repeal of these changes by supporting the passage of the Protecting Health Care and Lowering Costs Act (H.R. 4849/S. 2556) to reverse Medicaid funding cuts and repeal policies that reduce access to medically necessary audiology and speech-language pathology services.

Many states are financially struggling to absorb these federal changes to their Medicaid programs. Because states are required to cover certain services under federal law, they are left with few ways to cut costs other than cutting provider reimbursement rates and eliminating optional services in order to fix their budget shortfalls. Since OBBBA’s passage, Colorado, Idaho, and North Carolina have already cut Medicaid provider reimbursement rates.

Underlying Times Associated With CPT Code Usage and Payer Policies

It is within a payer’s purview (including that of state Medicaid agencies) to establish, enforce, or modify policies and reporting requirements for a given service. Some state Medicaid programs continue to use timed codes, but most states have moved to untimed codes, which align with intended use of CPT code 92507. Each of the 56 state and territorial Medicaid programs have different rules and requirements for their providers.

Every CPT code, whether it is untimed or timed, has underlying times derived from provider surveys for a “typical” patient in an outpatient setting. Untimed codes are intended to provide clinicians with flexibility to determine the appropriate amount of service time based on individual patient needs and professional judgment. However, it is important to recognize that untimed codes have always been valued according to their underlying times.

Below is a chart of common speech-language pathology codes with their underlying “typical” times from the 2026 physician work time files.

Medicaid Agencies Determine Coverage and Payment Policies

Medicaid is a health insurance program that is jointly funded by states and the federal government. Medicaid differs dramatically from Medicare. There are certain federal laws that Medicaid agencies must follow. Some of these include the Early and Periodic Screening, Diagnosis, and Treatment mandate—which requires coverage of all medically necessary services for Medicaid-enrolled children under age 21—and certain elements of the Patient Protection and Affordable Care Act (Obamacare)—like coverage of adults over age 21 if individual states choose to expand Medicaid. North Dakota is one of 41 states that have expanded Medicaid to include coverage for services for adults.

The Centers for Medicare and Medicaid Services (CMS) also publishes certain rules and regulations that state Medicaid programs must follow. While policies surrounding notice of changes to coverage and payment policies may be subject to different notice periods depending on the state, Medicaid agencies are allowed to change what they pay their providers and what services they cover, within any requirements laid out by state and federal law. In this situation, North Dakota Medicaid used its claims data to inform its policy changes to reflect the services and length of time its providers were using to serve beneficiaries.

ASHA does not and cannot control the policies of state Medicaid agencies. ASHA advocates with Medicaid agencies and health plans for better coverage of audiology and speech therapy services. While ASHA advises the code development and valuation process through participation in the American Medical Association’s CPT Editorial Panel and RUC, the valuation process directly informs—but does not control—Medicare’s payment policies.

There are upcoming changes to CPT code 92507 per the rate review process completed as part of the AMA CPT and RUC process, but those are separate from North Dakota Medicaid’s policy changes.

How ASHA Works With Medicaid Agencies

ASHA advocates for policies that benefit our members and the clients they serve across payers, including state Medicaid agencies and Medicaid managed care plans. We have hosted ASHA’s Payer Summit for staff members from health plans, utilization management companies, and Medicaid agencies in order to discuss better coverage of audiology and speech-language pathology services. We also submit comments to Medicaid agencies when policies positively or negatively impact our members and their clients.

ASHA Government Affairs and Public Policy staff work to advance ASHA’s Public Policy Agenda and respond to issues raised from the thousands of calls and emails from its 241,000 members every year. These calls often include issues with Medicaid agencies and their policies like North Dakota Medicaid’s changes.

Questions?

North Dakota Medicaid’s provider manual is the best source of information for coverage of speech therapy services. Contact North Dakota Medicaid at dhsmedicalservices@nd.gov.

You can also reach out to ASHA’s health care education and policy team at reimbursement@asha.org.