Coding and Payment of Cognitive Evaluation and Treatment Services
Considerations for Speech-Language Pathologists
Payment and coverage of speech-language pathology services related to the evaluation and treatment of cognitive impairments varies widely based on factors such as the patient’s medical condition, the payer, and the patient’s specific health insurance plan. It is critical for speech-language pathologists (SLPs) to understand coverage policies for the payers they commonly bill, to verify coverage for each patient prior to initiating services, and to be familiar with appropriate diagnosis and procedure coding for accurate claims submission.
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Payer Policies
It is important for SLPs to understand that there is significant variability in coverage for services for patients with cognitive impairments. Policies are often limited to services for patients diagnosed with specific medical conditions—such as stroke or traumatic brain injury (TBI)—and may also exclude cognitive services for specific conditions such as mild TBI, developmental disorders, or neurodegenerative diseases.
Always verify payer coverage policies before providing cognitive evaluation and therapy services. Generally, SLPs can find payer coverage guidelines in medical policy documents related to speech-language pathology services or cognitive therapy/rehabilitation. SLPs should seek guidance in the following areas:
- Whether cognitive evaluation and therapy services are covered
- What provider types are eligible to provide cognitive services
- Whether other factors contribute to level of coverage (e.g., the patient’s underlying medical condition or the setting in which services are provided)
- Whether there are requirements for prior authorization or specific visit limits
- Which Current Procedural Terminology (CPT®; American Medical Association) and International Classification of Diseases (ICD) codes are eligible for cognitive services
It is also critical for SLPs to establish medical necessity for cognitive evaluation and treatment services and provide clear documentation to support the need for the skilled care.
Medicare
Federal laws and regulations governing the provision of speech-language pathology services under Medicare do not as clearly define the role of SLPs in treating cognitive impairments as they do for speech, language, voice, and swallowing disorders. However, many local Medicare Administrative Contractors (MACs) do delineate a role for SLPs in this area of treatment through local coverage determinations (LCDs). Absent specific Medicare guidance regarding cognitive evaluation and therapy, SLPs should verify coverage with their local MAC and follow the Medicare Physician Fee Schedule (MPFS), generally accepted coding guidelines, and national guidelines as outlined in Medicare manuals, such as the Medicare Benefit Policy Manual.
Medicare Part A
Medicare Part A covers services provided in inpatient, facility-based settings as well as services provided under a home health plan of care.
Chapter 7 of the Medicare Benefit Policy Manual [PDF] for the home health benefit clearly outlines coverage for speech-language pathology services associated with speech, language, and swallowing disorders. However, there is no reference to cognitive services. There is also a limited number of home health LCDs that address speech-language pathology services. Absent direct Medicare guidance, work with the home health agency and the local MAC to verify coverage guidelines for cognitive services.
See also: Medicare Home Health Prospective Payment System
Chapter 8 of the Medicare Benefit Policy Manual [PDF] for skilled nursing facilities (SNFs) allows for coverage of speech-language pathology services when the condition arises after admission to the SNF or when the need for treatment ties directly to the prior acute care hospitalization. As such, it is critical for SLPs and the SNF to delineate a clear tie to the prior hospitalization through accurate coding and documentation. For example, a patient who was hospitalized for a hip fracture subsequently receives cognitive treatment in the SNF. Without appropriate documentation and coding, the service may be denied because there is no clear connection between the hip fracture and the need for cognitive treatment. However, if coding and documentation illustrates the hip fracture was caused by a fall and the fall was due to a cognitive deficit, treatment may be covered.
See also: Medicare Skilled Nursing Facility Prospective Payment System
Medicare Part B
Medicare Part B covers services provided in outpatient settings (e.g., private practice, outpatient clinic) or services provided to inpatient beneficiaries who have exhausted their Part A benefit.
Chapter 15 of the Medicare Benefit Policy Manual [PDF] for outpatient services clearly outlines coverage for speech-language pathology services associated with speech, language, and swallowing disorders. However, there is no direct reference to cognitive services. Several local MACs address coverage of cognitive evaluation and treatment in LCDs for Part B services. Each LCD outlines which CPT code(s) to use and provides a list of diagnoses that are considered medically necessary. Many LCDs limit cognitive treatment to TBI and stroke, citing the lack of research that demonstrates the efficacy of cognitive treatment for dementia or other neurodegenerative conditions. If there is no LCD in your state, work with the local MAC to verify coverage guidelines for cognitive services.
See also: Medicare Administrative Contractor Resources for Part B Services
Medicaid
Medicaid coverage of speech-language pathology services varies widely, as each state has the authority to determine its own guidelines. Coverage within a state may further vary depending on the patient’s age (e.g., pediatric vs. adult). Services for children under 21 may be covered because speech-language pathology is considered a mandatory service for children as a result of the federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) mandate. Speech-language pathology services to adults are considered optional services at the discretion of the state. Variation also exists as a result of the setting in which services are provided (e.g., school vs. health care). It is also common for Medicaid programs to limit coverage to cognitive therapy for deficits due to specific medical conditions (e.g., moderate to severe TBI, stroke, or encephalopathy). Cognitive treatment is often considered investigational and not medically necessary for other etiologies, such as mild TBI, dementia, developmental disorders (e.g., autism spectrum disorder), or neurodegenerative diseases (e.g., Parkinson’s disease, Alzheimer’s disease). SLPs should verify coverage through state-specific guidelines, which can be found in Medicaid guidance documents, such as the state provider handbook, or by contacting the state Medicaid agency.
See also: ASHA’s Medicaid Toolkit
Private Insurance
Like Medicaid, each private insurance plan can decide whether they will reimburse for cognitive therapy services. It is common for insurance plans to limit coverage to cognitive therapy for deficits due to specific medical conditions (e.g., moderate to severe TBI, stroke, or encephalopathy). Cognitive treatment is often considered investigational and not medically necessary for other etiologies, such as mild TBI, dementia, developmental disorders (e.g., autism spectrum disorder), or neurodegenerative diseases (e.g., Parkinson’s disease, Alzheimer’s disease). SLPs should verify coverage for each patient through health plan medical policies and the patient’s specific health insurance plan (e.g., employer-funded plan).
See also: ASHA’s Speech-Language Pathology Medical Review Guidelines [PDF]
Coding Considerations
Each claim that is submitted to a payer for reimbursement of cognitive evaluation and treatment should include both International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes to report the patient’s diagnosis and Current Procedural Terminology (CPT) codes to report the services provided by the SLP.
The following information is based on generally accepted coding principles. SLPs should consult the payer if clarification of coding or coverage is needed regarding a specific case.
ICD-10-CM Diagnosis Codes
Selection of the appropriate ICD-10-CM code(s) to report a cognitive deficit will depend largely on etiology.
Cerebrovascular Disease (Stroke)
Use the I69- series of ICD-10-CM codes to report cognitive deficits following cerebrovascular disease. Each category of cerebrovascular disease—nontraumatic subarachnoid hemorrhage, nontraumatic intracerebral hemorrhage, other nontraumatic intracranial hemorrhage, cerebral infarction, other cerebrovascular diseases, unspecified cerebrovascular diseases—includes codes for specific cognitive deficits, including memory, attention and concentration, frontal lobe and executive function, and cognitive-social deficits. The I69- series of codes is one of the few used by SLPs that incorporate both the medical diagnosis and treating diagnosis in one category. SLPs should always consult the medical record or referring physician to confirm the type of cerebrovascular disease before selecting an I69- code.
Traumatic Brain Injury (TBI)
The R41.84- series of ICD-10-CM codes is most commonly used to report cognitive deficits following TBI and includes specific codes for attention and concentration, cognitive communication, and frontal lobe and executive function deficits. Report this series of codes in conjunction with the S06- series to describe the type of TBI giving rise to the cognitive deficits. SLPs should always consult the medical record or referring physician to confirm the appropriate code to describe the type of TBI.
Other Neurological or Medical Conditions
For patients with a neurological or medical diagnosis other than TBI or stroke, such as epilepsy, brain cancer, autism spectrum disorder, or a neurodegenerative disease, SLPs may report R48.8 (other symbolic dysfunctions). This code is used to describe cognitive and language impairments when there is neurological information to support the diagnosis. SLPs should always consult the medical record or referring physician to obtain the appropriate code to describe the underlying medical condition.
No Related Medical Condition
Report the F80- series of codes for patients with language-based cognitive deficits but no related medical condition. For patients without a related medical condition or language deficit, consider ICD-10-CM code F88 (other disorders of psychological development). Informal descriptions for F88 include "cognitive developmental delay."
A detailed list of ICD-10-CM codes for SLPs [PDF] is available on ASHA’s website.
CPT Procedure Codes
Coding for evaluation and treatment is accomplished using the same CPT codes, regardless of the patient’s medical diagnosis. Following are CPT codes typically used by SLPs to report cognitive services.
96125 Standardized cognitive performance testing (eg, Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
97129 Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes (Report 97129 only once per day)
97130 each additional 15 minutes (list separately in addition to code for primary procedure)
(Use 97130 in conjunction with 97129)
(Do not report 97129, 97130 in conjunction with 97153, 97155)
Evaluation
SLPs should bill CPT code 96125 (standardized cognitive performance testing, per hour) if a standardized test is used and the combined time it takes to conduct the evaluation, interpret the results, and write the evaluation report is at least 31 minutes to report the first hour, 91 minutes to report the second hour, and so on. (See also: Billing Timed and Untimed Codes)
SLPs should not use 96125 to report tests that are identified as a screening tool in the test description or that do not meet the time requirements described above. For example, the Montreal Cognitive Assessment (MoCA) and Saint Louis University Mental Status (SLUMS) exam are described as screening tools and may not be reported with 96125. Subtests of standardized tests may be used only if the subtests themselves are standardized for independent administration.
CPT code 92523 (speech sound production and language evaluation) may be appropriate if the SLP is assessing cognitive-communication skills using only nonstandardized tools in conjunction with a full speech and language evaluation. However, speech and language abilities should be the dominant focus. There is no alternative for billing a cognitive-only evaluation that does not include standardized testing. Payers are increasingly placing emphasis on the use of standardized tests, and SLPs are encouraged to include them, even when not required for billing purposes.
Examples of appropriate standardized tests include, but are not limited to, Ross Information Processing Assessment —Second Edition (RIPA-2), Arizona Battery for Communication Disorders of Dementia (ABCD), and Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES).
Treatment
Effective January 1, 2020, CPT code 97127 (cognitive function intervention, per day) and Healthcare Common Procedure Coding System (HCPCS) code G0515 are deleted and replaced with two new timed codes: a base code for the initial 15 minutes of cognitive function intervention (97129) and an add-on code for each additional 15 minutes (97130). For more on these changes, see New and Revised CPT Codes for 2020. Use ASHA’s template letter [DOC] to help educate your payers regarding the new codes.
CPT code 92507 (speech, language, voice, and communication treatment) may also be appropriate if the focus of treatment is cognitive communication and if treatment goals are language-based. However, if the focus of treatment is primarily cognitive function, SLPs should report 97129 and 97130 unless specifically instructed by the payer.
Under the Medicare Part B (outpatient) program, 97129 and 97130 may not be billed with 92507 on the same day, by the same clinician. The National Correct Coding Initiative (NCCI) determines code pairs that may or may not be billed together on the same day, commonly known as "CCI edits."
Chapter 11, Section H-3 of the NCCI Policy Manual states:
A single practitioner shall not report CPT codes 92507 (treatment of speech, language, voice...; individual) and/or 92508 (treatment of speech, language, voice...; group) on the same date of service as CPT codes 97129 or 97533 (sensory integrative techniques to enhance...). However, if the two types of services are performed by different types of practitioners on the same date of service, they may be reported separately by a single billing entity. For example, if a speech language pathologist performs the procedures described by CPT codes 92507 and/or 92508 on the same date of service that an occupational therapist performs the procedures described by CPT codes 97129, 97533...a provider entity that employs both types of practitioners may report both services using an NCCI PTP-associated modifier.
See also: Medicare Part B CCI Edits for SLPs
There is no CPT code to report cognitive treatment provided in a group setting. Contact the payer directly for information regarding coverage of and coding for group cognitive treatment. (See also: Medicare Guidelines for Group Therapy and Modes of Service Delivery for Speech-Language Pathology)
A complete list of CPT codes for SLPs is available on ASHA’s website.
Time-Based Codes
CPT codes 97129 and 97130 are time-based codes. 97129 represents the first 15 minutes of treatment and can only be billed once per day. Bill 97130 in conjunction with 97129 for each additional 15 minutes of therapy. As an add-on code, 97130 must always be billed in conjunction with 97129 for each additional 15 minutes of therapy, when appropriate. 97130 may not be billed as a stand-alone code.
The base code and add-on code structure does not change how to calculate the number of total units that can be correctly billed for any given amount of time. As with other 15-minute time-based codes, think of 97129 as the first 15-minute unit and 97130 as subsequent 15-minute units. To bill the first unit (97129 base code), you must complete at least 8 minutes of face-to-face therapy. Any therapy less than 8 minutes total is not billable. To bill for a second unit (97130 add-on code) you must first complete a full 15 minutes of therapy (billed under 97129) plus at least 8 additional minutes (23 minutes total) to qualify to bill for 97130. To bill any subsequent add-on units, you must always complete the full time of the previous unit and exceed the halfway point of time to bill for the next unit, as outlined below. Keep in mind that only direct face-to-face therapy time may count towards billable units.
- 1 unit (97129): 8 minutes to 22 minutes
- 2 units (97129 + 97130): 23 minutes to 37minutes
- 3 units (97129 + 97130 + 97130): 38 minutes to 52 minutes
- 4 units (97129 + 97130 + 97130 + 97130): 53 minutes to 67 minutes
Billing Examples
97129 will always be the first unit billed, and may only be billed once per day, followed by the appropriate number of units of 97130. You must always fulfillat least 8 minutes of the final unit billed, as illustrated below.
- 13 minutes of therapy = 8 minutes (at least 8 minutes qualifies to bill 97129) + 5 minutes (does not qualify for 1 unit of 97130)
- 20 minutes of therapy = 15 minutes (97129) + 5 minutes (does not qualify for 1 unit of 97130)
- 23 minutes of therapy = 15 minutes (97129) + 8 minutes (1 unit of 97130)
- 36 minute of therapy = 15 minutes (97129) + 15 minutes (1 unit of 97130) + 6 minutes (does not qualify for an additional unit of 97130)
- 38 minutes of therapy = 15 minutes (97129) + 15 minutes (first unit of 97130) + 8 minutes (second unit of 97130)
Time-based codes may also include limits on how many units can be billed on the same day. For example, the Medicare Part B (outpatient) program publishes medically unlikely edits (MUEs) that limit 97129 to one (1) unit and 97130 to three (3) units per day for a total of four (4) units, even if the time spent exceeds 4 units. State Medicaid agencies must also use MUEs, but may modify them to meet their own needs. Other payers may also adopt MUEs. (See: Medicare Part B MUEs for SLPs)
See also: Billing Timed and Untimed Codes
Related Resources
- Questions? Need help with a denial of cognitive services? Contact reimbursement@asha.org.
- The ASHA Leader articles
- ASHA Practice Portal topics
