Changes Ahead for Speech-Generating Device Reimbursement SGDs—as part of a Medicare category that includes high-ticket equipment and are, therefore, often the target of fraud and abuse—face tighter restrictions. Bottom Line
Bottom Line  |   May 01, 2014
Changes Ahead for Speech-Generating Device Reimbursement
Author Notes
  • Mark Kander, is ASHA director of health care regulatory analysis. ■
    Mark Kander, is ASHA director of health care regulatory analysis. ■×
  • Lisa Satterfield, MS, CCC-A, is ASHA director of health care regulatory advocacy. ■
    Lisa Satterfield, MS, CCC-A, is ASHA director of health care regulatory advocacy. ■×
Article Information
Augmentative & Alternative Communication / Practice Management / Bottom Line
Bottom Line   |   May 01, 2014
Changes Ahead for Speech-Generating Device Reimbursement
The ASHA Leader, May 2014, Vol. 19, 26-27. doi:10.1044/leader.BML.19052014.26
The ASHA Leader, May 2014, Vol. 19, 26-27. doi:10.1044/leader.BML.19052014.26
As the Centers for Medicare and Medicaid Services tightens policies on Part B (outpatient) durable medical equipment, augmentative and alternative communication devices get swept up in changes designed more for power wheelchairs and diabetes supplies.
Speech-generating devices, a type of AAC device, have been covered by Medicare since 2001. Medicare classifies SGDs as durable medical equipment because they can withstand repeated use, are medical devices used for injury or a condition, and are appropriate for home use. Widespread fraud and abuse involving other items in the category, including mobility equipment and medical supplies, have triggered legislation and regulations to restrict who can get DMEs and the processes to obtain the often high-priced equipment.
Is there a new requirement that a patient has to visit a physician to get an SGD?
Yes, but the rule has yet to take effect. Under a provision of the Affordable Care Act, certain items—including SGDs—require documentation of a face-to-face visit with the ordering physician. This new rule does not change the longstanding requirement for an evaluation by a speech-language pathologist, but it does require the manufacturer or supplier to ensure that the user has, in fact, had a face-to-face visit with the physician within six months prior to obtaining the device.
Previous regulations required only that the ordering physician have a written evaluation signed by a certified SLP. This new provision, originally set for implementation on July 1, 2013, has been delayed several times; a new implementation date is expected sometime this year.
Does the beneficiary own or rent the device?
SGDs made the short list of items now available to Medicare beneficiaries only as rent-to-own—that is, Medicare pays the supplier a monthly fee for 13 months, after which the beneficiary owns the device.
The policy is harmful and dangerous to patients who require inpatient care during the rental period, as ASHA indicated to CMS in response to the proposed change, which went into effect April 1.
If a beneficiary requires inpatient care during the rental period, Medicare does not allow payment to the supplier during the hospitalization, when Part A covers patient costs. Because the Part B payments to the supplier stop, the supplier would then have to request the device be returned. Many SGD users have chronic, progressive conditions that require inpatient stays.
Without their SGDs, these patients cannot communicate with nurses, physicians and other inpatient caregivers, compromising their safety and health. Representatives of ASHA and a patient advocacy group recently met with with top-level CMS administrators to request that all SGDs be exempt from the capped rental policy. Immediate changes are not anticipated, but ASHA will continue to press CMS on this issue.
Will Medicare pay for tablets that, with appropriate apps, can be used as SGDs?
Medicare does not cover a tablet because it is not a dedicated medical device (that is, used only as an SGD).
ASHA has also addressed this issue with high-level CMS officials, who reiterated that Medicare will pay only for dedicated devices. They indicated that if less-expensive tablets and software are, indeed, viable options that could replace dedicated SGDs, there would be no reason to continue covering the dedicated devices. ASHA recognizes that some patients’ functional impairments require the technology and durability of the dedicated SGD, and will continue to advocate for access to the most efficient, clinically appropriate device that meets the beneficiary’s medical needs.
However, Medicare may cover tablet software or apps, if they can be obtained through a CMS-approved supplier. Medicare will not cover apps or software the user purchases independently.
Medicare and some Medicaid and private health plans recognize a software billing code under the Healthcare Common Procedure Coding System, which establishes DME billing codes: E2511, “Speech-generating software program, for personal computer or personal digital assistant.”
Medicare coverage for SGDs and software is identical nationwide: Generally, SGDs can be purchased only once every five years. This rule, however, is not clear for app purchases, and ASHA is seeking clarification from CMS. Regardless of the timing, however, the reimbursement must be to the CMS-approved supplier. The supplier, therefore, must document the delivery—with the tablet as the end user—because the app provider must be able to deliver updates and fixes.
How do I code SGD evaluation and treatment?
Medicare recognizes three Common Procedural Terminology (CPT © American Medical Association) codes for evaluation (92607 and 92608) and treatment (92609) for SGDs. It is not appropriate to use 92597 (evaluation for voice prosthesis) when billing for an SGD.
Medicare does not, however, include codes for non-speech generating devices (92605, evaluation, and 92606, treatment) in its fee schedule and does not reimburse separately for them.
In deciding to exclude the non-SGD codes from Medicare, CMS indicated that SLPs could perform non-SGD activities as part of broader evaluation and treatment. However, with four new specific evaluation codes replacing the general evaluation code (92505) in 2014, ASHA asked CMS to allow SLPs to use the non-SGD codes for separate reimbursement. Until the issue is resolved, SLPs should not bill separately for the non-SGD services.
What role does the federal government play in regulating SGDs?
No government entity carefully reviews the efficacy of traditional SGDs. The Food and Drug Administration reviews the user guides for new medical devices and equipment but focuses primarily on determining that the device is not harmful. The rationale for minimal review of non-life threatening devices is that health care consumers will stop purchasing devices that don’t work well.
In published guidance, the FDA explains that oversight of medical apps applies only to those that present a greater risk to patients if they don’t work as intended. The FDA encourages app developers to contact the agency with questions about the app’s level of risk and need for a premarket application. Licensed practitioners who create apps solely for use in their professional practice are not subject to FDA oversight.
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May 2014
Volume 19, Issue 5