Audiology and speech-language pathology services and devices are medically necessary to prevent, identify, evaluate, and treat speech-language, swallowing, cognitive-communication, hearing, and balance disorders.
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See also: Service Delivery Methods
A screening is a brief pass/fail procedure to identify individuals who require further assessment or referral to other professional and/or medical services. An assessment is more comprehensive, and it addresses speech, language, cognitive-communication, and/or swallowing function (strengths and weaknesses) in children and adults, including identification of impairments, associated activity and participation limitations, and environmental barriers that impact function.
An assessment is often prompted by referral, by the individual's medical status, educational performance, or by failing a speech-language or swallowing screening that is sensitive to cultural and linguistic diversity.
Assessments typically result in the following:
Determining medical necessity involves considering whether a service is essential and appropriate to the diagnosis and treatment of an illness, injury, or disease. Disease is defined as “an impairment of the normal state” (U.S. National Library of Medicine). Loss of hearing or balance, impaired speech and language, and swallowing difficulties all reflect an impairment of the “normal state,” and services to prevent or treat such impairment must be regarded as medically necessary.
Admission to audiology or speech-language pathology services is based on referral or self-referral. Criteria for delivering medically necessary services include one or more of the following:
One or more of the following criteria provide a basis for discharge from audiology or speech-language pathology services:
Other reasons for discharge include the following:
Although payers stipulate the parameters of services covered by their plan, ASHA's Code of Ethics and other guidance documents [PDF] support the independent clinical judgment of qualified audiologists and SLPs in delivering services and making recommendations. Clinical providers should not deliver or charge for unnecessary services, and they should not continue treatment after the patient has achieved maximum benefit.
Administrators should not mandate services based on quotas, productivity requirements, reimbursement levels, and other factors that do not relate to the individual needs of a patient/client. Similarly, administrators should not require clinicians to use codes, diagnoses, or treatment approaches when not indicated clinically.
Essential elements of documentation include the following:
The National Association of Insurance Commissioners' (NAIC) Glossary of Health Insurance and Medical Terms [PDF] defines the term rehabilitative services as follows:
Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
The NAIC's Glossary of Health Insurance and Medical Terms [PDF] defines the term habilitative services as follows:
Cover health care services and devices that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Habilitative services and devices meet the needs of a wide variety of children and adults with congenital deficits, autism spectrum disorder, cerebral palsy, disabilities, and other chronic and progressive conditions to acquire skills and functions never developed and to maintain their health and function.