December 2013
The Blue Cross Blue Shield of Michigan documentation guidelines for speech and language pathology services have been updated. Listed below are the guidelines to follow when providing these services:
- When speech and language pathology services are provided in a physician’s office, the physician must document the medical necessity for those services in the patient’s medical record.
- When speech services are provided in a location other than the physician’s office, the medical necessity for those services must be documented in the physician’s patient medical record. They also must be documented on the appropriate referral form from the physician to the speech-language pathologist.
The physician’s referral for therapy must be maintained in the speech pathologist’s patient medical record. The physician’s referral form must contain:
- Date of referral
- Date of onset of the condition (if appropriate)
- Medical diagnosis
- Physician’s signature and signature date
Note: Physician referrals expire after 120 days, even those that say “ongoing” or indicate a period longer than 120 days. In all cases, after 120 days, a new referral, signed and dated by the physician, must be obtained. (The date of the first treatment is the start of the 120-day period.)
We require the following information in the patient’s treatment record when speech pathology services are performed:
- Identifying information
- Patient’s name and address
- Patient’s contract number (including alpha prefix) and group number
- Patient’s date of birth
- Facility name and address (if applicable)
- Facility case number (if applicable)
- Location where services are provided
- Physician’s name and address
- Diagnosis and history
- Primary and all pertinent secondary diagnoses, with dates of onset (Diagnoses must be recognized medical diagnoses, not symptoms.)
- Diagnoses for which treatment is being provided, with onset dates
- Prior hospitalization and surgeries, with dates
- Other relevant patient history — such as exacerbation of a chronic illness, accidental injury, complicating medical problems, past treatment received — with onset dates and references to cause where relevant
Documenting the initial evaluation
For an initial evaluation, the certified or state-licensed speech-language pathologist must document the following information in the patient’s medical record, as is appropriate:
- Date of evaluation
- Date of injury or onset and description of exacerbation of a chronic condition
- Current status of the following:
- Diagnosis
- Age
- Functional level
- Level of speech intelligibility (with an objective measure and description of the level of severity of condition)
- Degree of language usage
- Indication of voice quality
- Swallowing ability
- Assessment of cognitive dysfunction
- Functional level prior to the onset of the current illness, injury or exacerbation
- Mental status and ability to participate in the treatment program (with reference to orientation, motivation, short-term memory, ability to follow directions, etc.)
- Pain level (as reported by the patient), type and the possible effect on the treatment program
- Treatment plan, including reference to the following:
- Communication disorders to be treated
- Treatment techniques and activities to be provided
- Frequency of treatments
- Duration of procedures
- Patient and family education (if applicable)
- Home treatment program
- Rehabilitation potential (a realistic evaluation of the patient’s potential for rehabilitation or restoration, in objective language)
- Treatment goals (therapeutic goals that are appropriate for the patient, the diagnoses, rehabilitation potential and the treatment to be provided)
- Anticipated duration of therapy (for example, three sessions per week for six weeks)
- Signature and credentials of the speech pathologist performing the evaluation
Documenting individual services or sessions
For each treatment session billed to BCBSM, the speech pathologist must document certain information in the patient’s treatment record. The following information may be documented in progress notes, a flow chart or a grid system of record keeping:
- Date of service
- Time of service if treatments are performed more than once per day (the use of a.m. or p.m. is acceptable)
- Treatment techniques and activities provided at the treatment session
- Patient’s response to the treatment
- Signature and credentials of the clinician providing treatment
Note: If the services are provided and documented by another person, the supervising speech-language pathologist or physician must co-sign the documentation.
Re-evaluating the response to treatment
The speech-language pathologist must write a treatment summary or progress note summarizing the patient’s response to treatment at least once every 60 days if treatment continues beyond a 60-day period.
Every treatment summary and progress note in the medical record must contain the following, as appropriate:
- Date of summary or progress note and the dates of service covered by the summary or progress note
- Specific and objective evaluation of the patient’s progress and response to treatment during the period
- Changes in medical status, which must be documented in clear, concise, objective statements
- Changes in mental status and level of cooperation, which must be documented in clear, concise, objective statements
- Change in treatment plan with rationale for the changes and reference to the patient’s readiness for discharge from treatment
- Signature and credentials of the clinician assessing the patient’s progress
The physician must also periodically evaluate and document the patient’s response to treatment. This can be accomplished through review of treatment summaries and recertification of the treatment plan. The requirements for physician involvement are as follows:
- When services are performed in a hospital inpatient setting, the physician must evaluate the patient at least once every 30 days.
- When services are performed in the hospital outpatient setting, freestanding outpatient therapy facility, physician office setting, hospice, skilled nursing facility or in the patient’s home, the physician must evaluate and recertify the treatment plan every 60 days.
- For speech pathology services beyond 60 days, the physician must evaluate and recertify the treatment plan every 60 days to determine whether continued therapy is needed and document the medical necessity for continuing the treatment.
Note: The period for recertification for long-term treatment plans is every 60 days. The previous requirement for a face-to-face physician visit for treatment-plan recertification is no longer in place.
Establishing ongoing communication
The physician and the speech-language pathologist must communicate every 16 visits or 60 days, whichever comes first. Communication may be in person, by phone or in writing.
The communication must be documented, including the date of communication, and must demonstrate ongoing communication between the referring physician and speech pathologist:
- Both the physician and the speech-language pathologist must document the substance of the verbal or written communication in the patient’s medical record.
- If the communication is in writing, such as in the form of a progress note or summary letter from the speech-language pathologist, the physician must include that document in the patient’s record and document that the information was reviewed and the plan for ongoing therapy approved.
- If the physician believes that further evaluation is required or that the treatment plan must be changed or discontinued, then the physician must communicate directly with the speech-language pathologist. Both the physician and the speech-language pathologist must document the discussion in their respective patient medical record.
You can review these changes in the “Documentation Guidelines for Physicians and Other Professional Providers” chapter of your online provider manual. To view the provider manual:
- Go to web-DENIS.
- Click on BCBSM Provider Publications and Resources.
- Click on Provider Manual.
