Initial ST Evaluations
Guidelines for ST Initial Evaluations
Purpose
The Initial Speech Therapy Evaluation establishes the patient's communication and/or swallowing baseline, identifies functional deficits, develops measurable goals, and initiates an individualized Plan of Care (POC) to address the patient's needs.
Policy
A physician order or referral is required before completing a speech-language pathology evaluation.
The evaluating Speech-Language Pathologist (SLP) is responsible for completing a comprehensive assessment, developing the Plan of Care, educating the patient and caregiver, initiating treatment when appropriate, and documenting all findings in the electronic medical record.
Scheduling Guidelines
The patient should be contacted to schedule the Initial Evaluation within 24 hours of assignment. Typical length of time for an initial evaluation is between 60-90 minutes. Note that patients who have United HealthCare are limited by insurance to 60 minute sessions.
With only very rare exceptions (which will be shared with you in the patient's HUCU channel), we encourage you to schedule your follow-up/treatment visits with the patient before you end the initial evaluation.
Evaluation Components
The Initial Evaluation may include one or more of the following services based on physician orders, clinical judgment, and patient needs:
Speech-Language Evaluation
Speech production and intelligibility
Language comprehension and expression
Cognitive-communication abilities
Voice and resonance
Functional communication skills
Patient and caregiver interview
Standardized and non-standardized assessments
Swallowing Evaluation
Review of relevant medical history
Oral mechanism examination
Assessment of swallowing safety and function
Diet and liquid consistency recommendations
Aspiration risk identification
Patient and caregiver education
Treatment Initiation
When clinically appropriate, treatment should begin during the Initial Evaluation visit. Treatment interventions may focus on:
Communication strategies
Speech and language rehabilitation
Cognitive-communication interventions
Voice therapy
Dysphagia management
Patient and caregiver training
Home exercise or home program instruction
Billing Guidelines
Services provided during the Initial Evaluation shall be billed according to the assessments and treatment performed and documented. Potential billable services may include:
Speech-Language Evaluation
Swallow Evaluation
Speech-Language Treatment
Dysphagia/Swallowing Treatment
When both an evaluation and treatment are provided on the same date of service, documentation must clearly support the medical necessity and distinct services performed.
Unless there is a specific diagnosis of a "voice only" disorder such as spasmodic dysphonia or vocal fold paralysis, do not bill the Voice Evaluation Code (92524).
LifeCare policy is to ensure that all therapy services rendered and billed meet Medicare regulatory requirements. While SLP codes are untimed, we want to avoid abusing this and billing charges that could trigger a Medicare audit of our billing practices.
Billing should generally follow the Medicare 15-minute rule, which means you can bill no more than 4 units within one hour of service.