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Modes of Service Delivery for Speech-Language Pathology

Clinical, Coding, and Payment Policy Considerations for Individual, Group, and Concurrent Therapy

ASHA and payers, such as the Centers for Medicare & Medicaid Services (CMS), state Medicaid programs, and commercial insurers, support service delivery based on the clinical judgment of the practitioner. Patient needs, clinical appropriateness, and evidence-based practice must drive service delivery option choices. When appropriate, speech-language pathologists (SLPs) should use varied modes of service delivery to effectively target functional outcomes in individuals they serve. The need for operational efficiencies does not override the clinical rationale for determining the appropriate mode of service delivery. Although all individuals benefit from individual therapy, when medically necessary, not all individuals/diagnoses/levels of impairment are appropriate for group and concurrent modes of therapy. Clinicians may also have limited options for service delivery modes, depending on payer policies and related coding constraints.

COVID-19 presents unique challenges to the delivery of group and concurrent therapy services. During the pandemic, please refer to the latest guidance from the Centers for Disease Control (CDC), the Centers for Medicare & Medicaid Services (CMS), and commercial insurers, as well as state and local regulations before initiating group or concurrent therapy in any practice setting.

Mode Clinical Considerations Payment Policy Considerations Coding Considerations
Individual

Definition: Individual therapy is one-on-one treatment to address a patient’s functional clinical needs. It is typically the primary mode of service delivery. Individual therapy is used to help a patient improve or maintain function.

Documentation: In individual therapy, documentation should always support medical necessity and the skilled nature of the services provided. ASHA’s Practice Portal on documentation in health care provides additional guidance.

Evidence: ASHA members are required to engage in evidence-based practice, in accordance with the ASHA Code of Ethics. ASHA’s evidence maps provide resources to evaluate current state of the science related to individual therapy in a variety of clinical diagnoses.

Individual therapy is dictated by the requirements of Current Procedural Terminology (CPT®) codes which require continuous, direct one-on-one patient contact, unless noted in the code description.

Clinicians must comply with the definition of each CPT code when reporting the services provided. ASHA's coding resources provide information on health care billing codes commonly used by SLPs.

Review medical policies and guidelines issued by payers for additional guidance regarding covered CPT codes. For example, Medicare Administrative Contractors (MACs) may publish local coverage determinations (LCDs) and coding articles to address speech-language pathology services.
Group

Definition: Group therapy is the provision of treatment, at the same time, to two or more individuals performing the same or similar activities. This does not mean that all participants have the same or similar goals. Group therapy may help a patient improve or maintain function.

Group therapy is an adjunct to—not a replacement for—individual therapy.

The needs of the patient and their targeted goals should drive the use of group therapy.

Group therapy is not a solution to operational efficiencies targeted by the clinician or the facility. If you believe that you are being required to perform group therapy regardless of patient need, use your clinical judgment to advocate on behalf of your patients.

Payers may have different policies or limitations on group therapy (e.g., limits on group size) within each episode of care. Recognizing these operational parameters, the most effective group size for any therapy session is determined solely by the clinician. Some factors to consider in this decision making include participants’ functional abilities, cognitive status, sensory needs, presenting complexity, and each participant’s ability to achieve the goals established in the plan of care.

Clients of varying diagnoses and levels of severity can effectively participate in a group.

All interventions used within the group session need to be skilled and medically necessary.

There are no passive observers in a group session. Every individual in the group should be able to participate meaningfully in the session, with facilitation by the clinician, in accordance with the established plan of care. 

Documentation: Minimum requirements for documenting a group session are as follows:

  • Justification for a group (vs. individual or concurrent) mode of service delivery for that treatment session
  • The specific goals targeted and how the group activity supported them
  • How activities used skilled interventions that were reasonable, medically necessary, and supported the patient’s established plan of care
  • Patient’s response to activities and related data

Evidence: ASHA members are required to engage in evidence-based practice, in accordance with the ASHA Code of Ethics. ASHA’s evidence maps provide resources to evaluate current state of the science related to group therapy in a variety of clinical diagnoses.

Commercial insurers and Medicaid: The coverage of group therapy by commercial insurers and Medicaid programs vary. SLPs should contact these payers directly for guidance on billing for group therapy.

Medicare: Medicare policies related to group therapy depend on the practice setting. Medicare coverage guidelines indicate that (a) the primary mode should be individual therapy and (b) group therapy should be an adjunct to individual therapy.

For Medicare Part A:

  • Inpatient rehabilitation facilities and hospitals: There is limited guidance regarding the use of group therapy. As such, the use of group therapy should be supported in the medical record.
  • Home health: Group therapy is not usually provided in the home health environment.
  • Skilled nursing facilities (SNFs): In Medicare Part A billing for SNFs, group therapy is restricted to two to six patients and can comprise no more than 25% of the episode of care. This 25% limitation is combined with concurrent therapy. 

For Medicare Part B: The coverage of group therapy is dictated by your MAC’s LCD. You can find your LCD via the Medicare Coverage Database. Select your state and use key terms such as “speech.”

See also: Medicare Guidelines for Group Therapy

CPT code 92508 describes treatment of speech, language, voice, communication, and/or auditory processing disorder; individual; group, two or more individuals. No CPT codes describe group treatment of swallowing or cognition. Clinicians should not use 92508 or individual therapy codes to bill group treatment for these other areas of impairment unless a payer specifically allows it.

Always check with payers directly regarding the use of 92508 to represent group therapy not associated with speech and language.

Payers may permit the use of CPT code 97150 to represent group therapy not associated with speech and language. CPT code 97150 is a physical medicine and rehabilitation code that represents group therapy more broadly. Check with the payer directly to determine if they will accept this code for group swallowing therapy when provided by an SLP.

Clinicians should not use individual therapy codes (e.g., 92507) to report group treatment.

Concurrent

Definition: Concurrent therapy is when the clinician treats two patients performing different activities, at the same time. Concurrent therapy should be skilled and medically necessary. It can be used to help a patient improve or maintain a level of function.

The use of concurrent therapy should always be based on the patient’s needs and targeted goals. The rationale should be evident in documentation.

Concurrent therapy is not a solution to operational efficiencies targeted by the clinician or the facility. If you believe you are being required to perform concurrent therapy regardless of patient need, use your clinical judgment to advocate on behalf of your patients.

Other payers may have different polices or limitations on concurrent therapy (e.g., limits on the number of patients seen at the same time) within each episode of care.

Clients with varying diagnoses and levels of severity can effectively participate in a concurrent session.

All activities used as part of the session need to be skilled and medically necessary.

Each individual in the concurrent session should be able to participate meaningfully in the session in accordance with their established plan of care, with appropriate facilitation and direct engagement by the clinician. 

Documentation: In a concurrent therapy session, documentation—at a minimum—needs to include the following:

  • Clinical rationale for employing a concurrent (vs. individual or group) mode of service delivery for that treatment session
  • The specific goal targeted and how the activity supported it, in ways unique to the concurrent mode of service delivery
  • How activities used skilled interventions that were reasonable, medically necessary, and supported the patient’s established plan of care
  • Patient’s response to activities and related data
Evidence: Currently, there are no published studies that have explored the concurrent mode of service delivery and its relative effectiveness over individual or group therapy in any area within the Speech-Language Pathology Scope of Practice.

Commercial insurers and Medicaid: The coverage of concurrent therapy for commercial insurers and Medicaid programs vary. SLPs should contact these plans directly for guidance on the use of concurrent therapy.

Medicare: Medicare coverage of concurrent therapy depends on the practice setting. Medicare coverage guidelines stress the expectation that the majority of treatment should be delivered in an individual mode and that concurrent therapy is an adjunct to individual therapy.

The Minimum Data Set Resident Assessment Instrument (MDS RAI) Manual states:

“Concurrent therapy is defined as the treatment of 2 residents at the same time, when the residents are not performing the same or similar activities, regardless of payer source, both of whom must be in line-of-sight of the treating therapist or assistant for Medicare Part A. When a Part A resident receives therapy that meets this definition, it is defined as concurrent therapy for the Part A resident regardless of the payer source for the second resident. For Part B, residents may not be treated concurrently: a therapist may treat one resident at a time, and the minutes during the day when the resident is treated individually are added, even if the therapist provides that treatment intermittently (first to one resident and then to another). For all other payers, follow Medicare Part A instructions.”

For Medicare Part A:

  • Inpatient rehabilitation facilities and hospitals: There is limited guidance regarding the use of concurrent therapy. As such, the medical necessity of concurrent therapy should be supported in the medical record.
  • Home health: Concurrent therapy is not commonly provided in the home health environment.
  • Skilled nursing facilities (SNFs): When billing SNFs for Medicare Part A, concurrent therapy is restricted to two patients and can comprise no more than 25% of the episode of care. This 25% limitation is combined with group therapy.
For Medicare Part B: Concurrent therapy is not a billable service.

SLPs typically bill individual therapy CPT codes for concurrent therapy. Keep in mind that clinicians must meet all requirements for individual therapy to bill a code for concurrent therapy. For timed codes (e.g., 97129, 97130), report the number of minutes spent in direct one-on-one treatment with each patient. For untimed codes (e.g., 92507), bill once per patient. Time is an important consideration, even for untimed codes. If clinicians spend only a short amount of direct one-on-one time with each patient, it may not be appropriate to bill for a full therapy session.

Check with payers directly to determine how concurrent therapy should be reported for billing purposes.

See also: The Right Time for Billing Codes

Questions?

Contact reimbursement@asha.org for additional information related to coding and payment for speech-language pathology services. For clinical questions, SLPs in health care can contact healthservices@asha.org.

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