Fluency Treatment Reimbursement Battle Most health insurance companies continue to deny reimbursement for fluency treatment, citing lack of medical necessity, despite raised awareness of the disorder and relatively recent changes in fluency diagnosis codes. Last year’s Academy Award-winning movie “The King’s Speech” accurately depicted the communication difficulties of stuttering as well as its harmful ... Bottom Line
Free
Bottom Line  |   February 01, 2012
Fluency Treatment Reimbursement Battle
Author Notes
  • Janet McCarty, MEd, CCC-SLP, private health plans advisor, can be reached at jmccarty@asha.org.
    Janet McCarty, MEd, CCC-SLP, private health plans advisor, can be reached at jmccarty@asha.org.×
  • Laurie Alban Havens, MA, CCC-SLP, director of Medicaid and private health plans advocacy, can be reached at lalbanhavens@asha.org.
    Laurie Alban Havens, MA, CCC-SLP, director of Medicaid and private health plans advocacy, can be reached at lalbanhavens@asha.org.×
Article Information
Speech, Voice & Prosodic Disorders / Fluency Disorders / Practice Management / Speech, Voice & Prosody / Bottom Line
Bottom Line   |   February 01, 2012
Fluency Treatment Reimbursement Battle
The ASHA Leader, February 2012, Vol. 17, 1-3. doi:10.1044/leader.BML1.17022012.1
The ASHA Leader, February 2012, Vol. 17, 1-3. doi:10.1044/leader.BML1.17022012.1
Most health insurance companies continue to deny reimbursement for fluency treatment, citing lack of medical necessity, despite raised awareness of the disorder and relatively recent changes in fluency diagnosis codes.
Last year’s Academy Award-winning movie “The King’s Speech” accurately depicted the communication difficulties of stuttering as well as its harmful psychological and emotional effects. The film’s ability to raise public awareness, however, did not translate into greater understanding by health insurance companies of the need for treatment.
Changes to the codes for fluency disorders in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)—which indicate that stuttering is an “illness”—also have not improved payment as anticipated. These codes became effective Oct. 1, 2010 (see The ASHA Leader, Sept. 21, 2010).
The new fluency codes followed extensive ASHA lobbying. The fluency proposal was first presented at the ICD-9-CM Coordination and Maintenance Committee meeting in September 2008 and a revised proposal was presented at the September 2009 meeting.
After more revisions and negotiations, the final proposal recommended additions and revisions to the ICD-9-CM that would “better capture the nature and description of fluency disorders.”
Definition
Under the ICD-9-CM, stuttering is an illness, as evidenced by its classification and assigned diagnostic code. One of the 2010 changes is a new 2010 ICD-9-CM code, 315.35 (“childhood onset fluency disorder”), which should be used regardless of current age if the stuttering onset occurred during childhood. The code is listed in the “Specific Delays in Development” section of the ICD-9-CM, but is not a developmental condition; therefore, health plans that exclude “developmental” conditions should not deny coverage based on that exclusion alone.
The wording used in 315.35 was chosen deliberately to reflect the fact that the stuttering is not present early in the child’s development, but rather has an observable onset, typically in preschool, and occurs after normal speech-language development and fluency are evident.
Additional fluency codes in the ICD-9-CM include:
  • 307.0 (adult onset fluency disorder)

  • 438.14 (stuttering due to late effect of cerebrovascular accident)

  • 784.52 (fluency disorder in conditions classified elsewhere, such as Parkinson’s disease).

Code 315.35 also should be used to describe cluttering and stammering.
Evidence
Further support for payment comes from research indicating the physiological nature of stuttering as an illness category. According to studies, adults who stutter may have anatomical irregularities in the areas of the brain that control language and speech (Neurology, July 24, 2001). This research should be referenced in appeals (a sample letter [PDF] is available at ASHA’s website).
ASHA’s Stuttering Treatment Efficacy Summary reports that treatment for stuttering results in improvement for about 70% of all cases across the life span. ASHA’s National Outcomes Measurement System found that 64% of children ages 5–11 with fluency disorders progressed by at least one functional communication level with more than 12 hours of treatment.
ASHA encourages clinicians to appeal denials and to promote improved coverage in health plans. ASHA remains active in advocating for coverage of stuttering by health plans and is available to members appealing a denied fluency claim or promoting fluency coverage.
0 Comments
Submit a Comment
Submit A Comment
Name
Comment Title
Comment


This feature is available to Subscribers Only
Sign In or Create an Account ×
FROM THIS ISSUE
February 2012
Volume 17, Issue 2