Medicare recognizes speech-generating devices (SGDs) as Durable Medical Equipment (DME), which is a covered benefit for Medicare beneficiaries under the Social Security Act (Section 1861). On July 29, 2015, the Centers for Medicare & Medicaid Services (CMS) issued changes to the SGD benefit in a Final Decision Memorandum, reflected here. The decisions outlined in the memorandum are effective immediately.
Effective July 29, 2015, the Medicare definition includes devices that:
The definition excludes from Medicare coverage:
The excluded features can be added to the SGD at the patient's expense.
DME is defined by Medicare as "reusable" medical equipment and is covered under Medicare Part B (outpatient) services when it is necessary for use in the home (or facility that is used as a home, such as a long-term care facility). SGDs required in inpatient facilities (skilled nursing facilities, inpatient hospitals) are the responsibility of the facility.
The decision outlined in the July 29, 2015, Final Decision Memorandum are effective immediately. Devices that are under the capped rental period from July 29, 2015, through September 30, 2015, can have the expanded capabilities according to the definition above.
The regional Centers for Medicare & Medicaid Services (CMS) Medicare Administrative Contractors (MACs) have issued Local Coverage Determinations (LCDs) that outline requirements for SGD reimbursement, which includes an evaluation by a speech-language pathologist (SLP).
The LCDs also include the requirement of the physician face-to-face visit prior to the prescription of the SGD. The face-to-face physician visit originates from the Affordable Care Act and mandates that the documentation of the visit with the physician demonstrates the beneficiary was evaluated and/or treated for a condition that supports the need for the SGD. A dispensing order is not sufficient documentation; a Written Order Prior to Delivery (WOPD) is required and must be forwarded to the supplier prior to the delivery of the SGD. In the case of an audit, the supplier is responsible for the WOPD.
Medicare will only reimburse a Medicare-enrolled DME provider that has met the requirements in the Medicare Program Integrity Manual.
Due to coordinated advocacy efforts from ASHA members, manufacturers, and the patient community, Congress passed the Steve Gleason Act of 2015, which excepts SGDs from the capped rental requirements for devices acquired on or after October 1, 2015, allowing initial purchase of the device. For devices obtained prior to October 1, 2015, the capped rental rules applied, but are unlikely to have an ongoing impact. Effective July 29, 2015, devices are allowed the extra features that were previously denied due to the "dedicated" SGD requirement and the devices could be directly purchased.
CPT codes 92607-92609 relate to speech-language pathology services for SGDs. CPT 92607 is used for coding the first hour of the evaluation for an SGD prescription. CPT 92608 allows the SLP to bill for each additional 30 minutes. Therapeutic services for the use of an SGD are reported using 92609.