Mississippi Administrative Code
Title 23 - Division of Medicaid
Part 213 - Therapy Services
Chapter 3 - Outpatient Speech-Language Pathology (Speech Therapy)
Rule 23-213-3.3 - Covered Speech-Language Pathology and Audiology Services
Universal Citation: MS Code of Rules 23-213-3.3
Current through September 24, 2024
A. The Division of Medicaid covers speech-language pathology and audiology services in the outpatient setting when medically necessary, ordered by a physician, physician assistant or nurse practitioner, for the diagnosis and treatment of a communication impairment and/or swallowing disorder due to disease, trauma, or congenital anomaly and prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or a designated entity and the following requirements are met:
1. The services require
the knowledge, skill and judgment of a state-licensed speech-language
pathologist or audiologist.
2. The
Certificate of Medical Necessity (CMN) for initial referral/order is completed
by the prescribing provider prior to the speech-language pathology or audiology
evaluation.
3. The plan of care
(POC) is developed by a state-licensed speech-language pathologist or
audiologist.
4. The prescribing
provider approves the initial/revised POC with a signature and date:
a) Before the initiation of treatment or
change in treatment, or
b) Within
thirty (30) calendar days of the verbal order for the initial treatment plan or
change in treatment.
5.
The services are rendered as individualized speech language pathology or
audiology services consistent with the symptomatology/diagnosis and do not
exceed the beneficiary's needs.
6.
The services do not duplicate another provider's services including those
services provided in a school-based setting.
7. The beneficiary presents with one (1) or
more of the following:
a) Aphagia defined as
an inability to swallow,
b)
Aphasia defined as an absence/impairment of the ability to communicate through
speech, writing, or signs caused by focal damage to the language dominant
hemisphere of the brain,
c)
Aphonia defined as an inability to produce sounds from the larynx due to
excessive muscle tension, paralysis, or disease of the laryngeal nerves,
d) Apraxia defined as an inability
to form words to speak despite an ability to use facial and oral muscles to
make sounds,
e) Dysarthria defined
as defective or difficult speech that involves disturbances in muscular control
like weakness, lack of coordination, or paralysis of the speech mechanism,
either oral, lingual, respiratory or pharyngeal muscles, resulting from damage
to the peripheral or central nervous system,
f) Dysphagia defined as difficulty
swallowing,
g) Dysphasia defined
as language impairment from neurodevelopmental disorder or brain lesion,
h) Dysphonia defined as difficulty
speaking due to impairment of the muscles involving vocal production, and/or
i) Vocal cord dysfunction defined
as impairment of vocal cord mobility due to functional or structural
abnormalities resulting from organic or neurological diseases.
8. Risk factors have been
identified and documented including, but are not limited to:
a) Neurological disorders/dysfunctions, such
as hearing loss or cerebral palsy,
b) Surgical procedures, such as
partial/comprehensive/radical laryngectomy, repaired cleft palate, or
glossectomy,
c) Cognitive
impairments that affect communication functions, or
d) Medical conditions resulting in
communication disorders that require restorative therapy including, but not
limited to:
1) Laryngeal carcinoma requiring
partial/total largyngectomy that results in dysphonia or aphonia,
2) Traumatic brain injury that may exhibit
inadequate respiratory volume, apraxia, dysphagia, or dysarthria,
3) Progressive/static neurological
conditions, such as amyotrophic lateral sclerosis, Parkinson's disease,
myasthenia gravis, multiple sclerosis, or Huntington's disease,
4) Intellectual disability with disorders of
dysarthria, dysphagia, apraxia, or aphagia, and/or
5) Cerebrovascular disease, such as
cerebrovascular accident, presenting with apraxia, aphasia, dysphagia, or
dysarthria.
9. The type of service requested includes one
(1) or more of the following:
a) Diagnostic
and evaluation services:
1) To determine the
type, causal factors, severity of speech-language or swallowing disorders, and
the extent of service required to restore functions of speech, language, voice
fluency, and swallowing, or
2) The
beneficiary demonstrates changes in functional speech or remission of a medical
condition that previously contradicted speech-language therapy.
b) Therapeutic services defined as
services requiring active corrective/restorative therapy, for communication
disorders that result from:
1) Laryngeal
carcinoma requiring partial/total largyngectomy that results in aphonia so the
beneficiary can develop new communication skills through esophageal speech or
the use of an electrolarynx,
2)
Cerebrovascular disease, such as cerebrovascular accident, presenting with
apraxia, aphasia, dysphagia, or dysarthria, or
3) Medical and neurological conditions, like
traumatic brain injury, Parkinson's disease, or multiple sclerosis, exhibiting
inadequate respiratory volume/control, aphonia, dysphagia, dysarthria, or
dysphonia.
B. The Division of Medicaid reimburses for covered speech-language pathology or audiology services provided by:
1. A state-licensed speech-language
pathologist or audiologist.
2. A
state-licensed speech-language pathologist or audiologist assisted by a
state-licensed speech-language pathologist or audiologist assistant under
direct, on-site supervision by a state-licensed speech-language pathologist or
audiologist.
a) The Division of Medicaid
defines direct, onsite supervision as face-to-face oversight by a
state-licensed speech-language pathologist or audiologist at regular intervals,
congruent with the standards of the American Speech-Language-Hearing
Association (ASHA) and does not include:
1)
Contacts by telephone,
2) Contacts
by pager,
3) Video conferencing,
and/or
4) Any method not approved
by the Division of Medicaid.
b) The initial evaluation, POC, and discharge
summary must be completed by a state-licensed speech-language pathologist or
audiologist.
3. A
state-licensed speech-language pathologist or audiologist assisted by a
speech-language pathology or audiology student who is enrolled in an accredited
speech-language pathology or audiology program while completing the clinical
requirements necessary for graduation under direct, on-site supervision of a
state-licensed speech-language pathologist or audiologist, referred to as
student assisted speech-language pathology or audiology services.
a) The Division of Medicaid defines direct,
on-site supervision of a speech-language pathology or audiology student as the
face-to-face oversight by a state-licensed speech-language pathologist or
audiologist.
b) The state-licensed
speech-language pathologist or audiologist must be physically present and
engaged in student oversight during the entirety of a therapy session such that
the state-licensed speech-language pathologist or audiologist is considered to
be providing the speech-language pathology or audiology service.
C. The state-licensed speech-language pathologist or audiologist cannot supervise at the same time during the work day more than:
1. One (1)
speech-language pathology or audiology student,
2. A total of four (4) state-licensed
speech-language pathologist or audiologist assistants, or
3. One (1) speech-language pathology or
audiology student and three (3) state-licensed speech-language pathologist or
audiologist assistants.
42 CFR § 410.61 -62; Miss. Code Ann. § 43-13-121.
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