This policy describes CPT codes from the Physical Medicine and Rehabilitation, Evaluation and Management, Adaptive Behavior Assessment and other sections of the CPT manual that will not be reimbursed, when reported by Speech-Language Therapists/ Pathologists.
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Consistent with the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA), UnitedHealthcare will not reimburse Speech-Language Therapists/Pathologists for therapeutic procedures, evaluation and management services, adaptive behavior assessments and other codes listed on the “Services Not Reimbursable to Speech-Language Therapists/Pathologists” code list found below.
Speech-language pathology services are those services provided:
Consistent with CMS, services must relate directly and specifically to a written speech therapy treatment plan (also known as a plan of care or plan of treatment) and must be established before treatment has begun. Therapy may be initiated by a Speech-Language Therapist/Pathologist, based on the plan of care. The plan of care must specify the speech therapy services planned.
There shall be different plans of care for each type of therapy discipline. For example, a Speech Therapist may not provide services under a physical therapy plan of care. However, both may be treating the patient for the same condition.
Modifiers are used to identify therapy services, whether or not financial limitations are in effect. Healthcare Common Procedure Coding System (HCPCS) modifier GN (services delivered under an outpatient speech-language pathology plan of care) should be submitted with any speech therapy service codes, provided by a Speech-Language Pathologist, that are considered by CMS to be “always therapy” services. However, the use of the GN modifier does not allow a Speech Therapist/Pathologist to deliver services they are not qualified and recognized to perform.
Other reimbursement policies that address reimbursement for the codes reported may also apply.