Cognitive Treatment: Is It Covered? Reimbursement policies for SLP-provided cognitive assessment and treatment depend on payer, facility, patient’s diagnosis and type of treatment. Bottom Line
Bottom Line  |   March 01, 2017
Cognitive Treatment: Is It Covered?
Author Notes
  • Laurie Alban Havens, MA, CCC-SLP, is director of ASHA private health plans and Medicaid advocacy.
    Laurie Alban Havens, MA, CCC-SLP, is director of ASHA private health plans and Medicaid advocacy.×
  • Janet McCarty, MEd, CCC-SLP, is director of ASHA private health plan reimbursement.
    Janet McCarty, MEd, CCC-SLP, is director of ASHA private health plan reimbursement.×
  • Monica Sampson, PhD, CCC-SLP, is associate director of ASHA health care services.
    Monica Sampson, PhD, CCC-SLP, is associate director of ASHA health care services.×
  • Sarah Warren, MA, is director of ASHA health care regulatory advocacy.
    Sarah Warren, MA, is director of ASHA health care regulatory advocacy.×
Article Information
Practice Management / Attention, Memory & Executive Functions / Bottom Line
Bottom Line   |   March 01, 2017
Cognitive Treatment: Is It Covered?
The ASHA Leader, March 2017, Vol. 22, 24-26. doi:10.1044/leader.BML.22032017.24
The ASHA Leader, March 2017, Vol. 22, 24-26. doi:10.1044/leader.BML.22032017.24
Speech-language pathologists evaluate and treat communication difficulties related to many causes, including cognitive deficits resulting from conditions such as dementia, stroke and traumatic brain injury. Although assessment and treatment of cognitive deficits are clearly in SLPs’ scope of practice, some public and private payers are putting up roadblocks to reimbursement for these services.
Payers are carefully scrutinizing clinical services targeting cognition. Medicare has even instituted payment policies that challenge—but do not necessarily preclude—coverage of these services. Private health plans often base cognitive treatment coverage on etiology (the underlying cause of the disorder), and specifically exclude some conditions that require cognitive treatment.
To ensure they receive reimbursement for these cognitive-related services, SLPs need to arm themselves with solid, clear documentation of medical necessity and evidence-based services. They also need to be familiar with coding and coverage policies for the evaluation and treatment of cognitive deficits, as well as emerging management trends among payers. Here are answers to some frequently asked questions about cognitive treatment.
Does Medicare cover SLP-provided cognitive services?
Medicare coverage is governed by national regulations issued by the Centers for Medicare and Medicaid Services (CMS) and outlined in manuals. There is no specific statement in any of these documents that excludes coverage for SLP-provided cognitive evaluation and treatment. However, the manuals do not specifically list cognitive evaluation and treatment as within the speech-language pathology scope of practice, leading to flexibility in coverage interpretations.
If Medicare has national regulations, why are there questions?
Although CMS provides national regulations, the local Medicare Administrative Contractors (MACs) issue local coverage determinations (LCDs) that, in some cases, further refine or limit Medicare rules. LCDs outline the covered codes for procedures (designated by Current Procedural Terminology, or CPT codes) and diagnoses (designated by the International Classification of Diseases, or ICD codes).
Some LCDs deal with treatment and diagnosis codes SLPs use in providing cognitive evaluation and treatment. It is critical, therefore, to review any relevant LCDs, including the list of covered ICD and CPT codes.
For example, ICD codes R48.8 (other symbolic dysfunctions) and R41.841 (cognitive communication deficit) both can be used to capture cognitive deficits and support use of CPT 97532 (development of cognitive skills to improve attention, memory, problem solving, direct one-on-one patient contact by the provider; each 15 minutes).
Additional ICD codes indicating the related medical condition may also be required, and would dictate the SLP’s choice of diagnostic code assignment.
Some LCDs require specific matching of CPT and ICD codes. For example, in the LCD issued by National Government Services, the CPT code 97532 must be paired with an ICD code from a specific list. In many of these situations, the choice of ICDs is fairly extensive. However, some LCDs omit certain diagnosis codes that, in fact, warrant the code. ASHA actively works with MAC medical directors to request changes to LCDs.
Some LCDs may cover a specific practice setting, such as home health agencies; specific clinical specialties, such as speech-language pathology; or specific conditions or procedures, such as dysphagia.
Are there other Medicare considerations?
MACs often interpret federal language differently. In many cases, these interpretations pose some troubling trends for cognitive-service coverage, especially in skilled nursing facilities (SNFs) and home health agencies (HHAs).
For example, Chapter 7 of the Benefit Policy Manual, which outlines guidelines for HHA services, appears to restrict SLPs’ services to the areas of speech/voice production, communication, feeding, aphasia and voice disorders. Although cognition is not specifically excluded, neither is it specifically included. MACs have used this language to deny home-health cognitive services.
However, if the MAC has a home-health LCD specifically including cognitive communication, that information could be used to appeal the denial.
Another example concerns Chapter 8 of the Medicare Benefit Policy Manual, which governs Medicare Part A coverage of services in SNFs (in all cases, SNF admission requires a previous hospital stay). It states that SNF patient care is covered for the condition that was treated during the qualifying hospital stay, or for a condition that arose while in the SNF. Therefore, if a patient had a stroke leading to hospital admission and subsequent discharge to a SNF, or if he has a stroke while recovering in a SNF after hospitalization for another illness or surgery, all cognitive and communication services that patient needs are likely to be covered by Medicare.
However, coverage guidelines are less clear if the patient’s hospital discharge/SNF-admitting diagnoses are not specifically associated with the patient’s cognitive changes. A patient with a hip fracture caused by a fall, for example, who received no speech-language services (or perhaps just dysphagia services) while in the hospital may have pre-existing—but undocumented—cognitive deficits (that may have contributed to the fall). If the SLP in the SNF evaluates and treats these deficits, it could raise concerns for Medicare that the SNF is not adhering to coverage guidelines.
Coverage may be wholly appropriate, however, if the SLP presents a complete picture of the patient—one that documents the cognitive deficits that either contributed to the patient’s hip fracture or that resulted from a fall and its impact on the patient’s current ability to participate in activities of daily living.
How do I appeal a Medicare denial?
Accurate coding and strong documentation could assist clinicians and their employers with successfully overturning Medicare denials. Successful appeals require immediate action when services are denied: development of appeals materials, thoughtful and complete assessment of the denial rationale, and the commitment of the facility to launch appeals based on their merit rather than on whether an appeal is financially worth the effort.
There are five stages in the Medicare appeals process, each with a specific time frame, so a facility must notify treating clinicians immediately if it plans to appeal a denial.
Does Medicaid cover cognitive treatment?
Depending on the state, Medicaid may cover cognitive treatment under CPT 97532, and about half the states list it as a billable code. Medicaid has adopted Medicare’s National Correct Coding Initiative rules, which state that 97532 cannot be billed on the same day as 92507 (individual treatment of speech, language, voice, communication, and/or auditory processing disorder). However, states may ask CMS to approve editing or deactivating an individual edit if it conflicts with a state law, regulation, rule or payment policy.
A few state Medicaid programs allow cognitive treatment to be billed under 92507 as an umbrella code for any speech-language services provided.
As with all Medicaid questions, it’s best to check the provider manual and fee schedule for the state’s Medicaid program to verify policies.
How do I know if a patient’s private health plan will cover cognitive-related services?
Private health plans cover cognitive rehabilitation for certain conditions, but not all—despite substantial evidence, including outcomes data and systematic literature reviews, that supports cognitive rehabilitation for a number of etiologies, including mild–severe traumatic brain injury (TBI), encephalitis and stroke.
For example, many private payers—including UnitedHealthCare, Cigna, Aetna and many Blue Cross Blue Shield plans—cover cognitive rehabilitation, but only for TBI and stroke. Some plans will also cover cognitive rehabilitation for encephalopathy or brain toxins (chemotherapy-related cognitive deficits).
But Anthem, the largest Blue Cross Blue Shield plan with 70 million beneficiaries, consistently denies coverage for stroke-related cognitive rehabilitation.
Health plans may deny coverage for cognitive rehabilitation because they view the treatment as “investigational.” Review each plan’s coverage policy to determine if the patient’s diagnosis is covered.
Do private plans follow Medicare coding policy?
Most private health plans follow Medicare coding policy that allows only 92507 or 97532 to be billed in one day. If you see the patient for speech and language goals, use 92507. If you see the patient for pure cognitive goals, use 97532.
New ICD cognitive deficit codes related to cerebrovascular accident (CVA) went into effect Oct. 1, 2016, and may better support CVA-related cognitive rehabilitation. The new ICD-10 CVA cognitive deficit codes may also better distinguish the cognitive treatment from services provided under CPT 92507 and captured under appropriate diagnostic codes—such as I69.020, aphasia following nontraumatic subarachnoid hemorrhage.
How can I overcome these payment policy challenges?
Many members contact ASHA with concerns and questions about cognitive evaluation and treatment coverage. In some cases, employers that receive denials may recommend that SLPs use inaccurate coding practices to avoid denials and obtain payment. Although appropriate evidence-based practice should drive payment policy—not the other way around—in the real world, SLPs need to balance compliance with their employer’s requests with ethical practice. Here are some strategies:
  • Provide evidence-based services appropriately tailored to meet your patient’s individual functional needs.

  • Accurately code for deficits and clearly document a patient’s needs and functional status in measurable ways. Changing coding practices to avoid denials may prove successful in the short term, but your documentation must support the codes.

  • Advocate for the value of your services with your employer, demonstrating how your treatment improves patients’ functional status.

  • Offer to work with your facility to appeal denials.

  • Advocate for yourself and your patients to provide the highest quality of services. If you are concerned that your employer is adopting inappropriate strategies to mitigate payer denials, consult resources developed by ASHA and other associations, including the American Physical Therapy Association, the American Occupational Therapy Association and the National Association for the Support of Long-Term Care: Compliance Reporting and Consensus Statement on Clinical Judgment.

  • Educate your employers on appropriate coding and documentation and determine when they will appeal denials.

  • Help administrators understand the long-term implications of inappropriate coding.

What other resources are available?
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March 2017
Volume 22, Issue 3