Proper Utilization of Speech Assistants/Aides in Healthcare

Proper Utilization of Speech Assistants/Aides in Healthcare – Christine Gibson, MSHA Vice-President: Healthcare

I have had many inquiries regarding use of speech assistants/aides (SLPAs) and Medicare guidelines and would like to provide clarification. Here are some of the most commonly asked questions:  1.   Can a speech pathologist bill for therapy minutes provided by a speech assistant/aide?  2.  In MS, aides are registered under the SLP. Does this mean the supervising therapist may bill for the services performed by the aide/assistant?   3.  Does this rule apply across all healthcare settings, including inpatient rehab facilities, skilled nursing facilities, home health, and outpatient?   4. What if the local coverage determination (LCD) or fiscal intermediary, now Medicare Administrative Contractor (MAC), says that speech assistants/aides minutes are billable therapy? Does the national coverage determination prevail?

The fact that Mississippi SLPA registration is under an SLP’s license does not cause Medicare to determine their services are equal to an SLP.  Mississippi state regulations governing speech pathologists Title 15 – Mississippi Department of Health Part III – Office of Health Protection; Subpart 60 – Professional Licensure, Section 109.10 Duties of the Speech-Language Pathology or Audiology Aide limits SLPA services directly provided to patients to the following:

Some speech-language activities such as repetitive drills are routinely assigned to a parent, caretaker, or significant other for stabilization/generalization purposes. This is done after the speech-language pathologist has introduced and taught the client the target sound or language concept. These types of drill activities are allowed.

Mississippi Medicaid does not cover services provided by speech assistants or aides.  This is clearly stated in section 49.06 of the Division of Medicaid State of Mississippi Provider Policy Manual.

On a federal level, Medicare does not consider repetitive drills and tasks that can be routinely assigned to a parent, caretaker, or significant other for stabilization/generalization a skilled therapy service.  It is unskilled and not considered therapy.  According to Chapter 15 – Covered Medical and Other Health Services 230.3 – Practice of Speech-Language Pathology (Rev. 106, Issued: 04-24-09, Effective: 07-01-09, Implementation 07-06-09):

C. Services of Speech-Language Pathology Support Personnel

Services of speech-language pathology assistants are not recognized for Medicare coverage. Services provided by speech-language pathology assistants, even if they are licensed to provide services in their states, will be considered unskilled services and denied as not reasonable and necessary if they are billed as therapy services.

Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.

Officially, sec. 15/230.3 applies to outpatient/Part B services.  However, Chapter 1 (Hospitals) of the Benefit Policy Manual refers to Chapter 15 for services not specific to covered inpatient hospital services. See the Medicare Benefit Policy Manual, Chapter 1, “Inpatient Hospital Services.”   Thus, an inpatient rehabilitation facility would not use SLPA’s and apply their services to the 3-hour/week rehab therapy requirement.  This would also apply to acute care. Chapter 8 (Skilled Nursing Facilities) refers to the policy set forth in Chapter 1 (Hospitals) and, therefore, does not cover services provided by speech assistants/aides. Ultimately, SLPA services are not billable and are not skilled therapy and this applies to all settings in the healthcare continuum.

 Regarding Local Coverage Determinations (LCDs) effective in Mississippi – – The purpose of an LCD is to: 1.   Address issues that are not mentioned in the national policy manuals.  2.  Clarify issues in national policy manuals that are not clear or ambiguous.  3.  Include key topics from the national manuals, usually in summary form.

Should you ever determine that the Medicare Administrative Contractor has included information in its LCD that is inappropriate based on the above points, please notify Mark Kander (, Director, Health Care Regulatory Analysis, American Speech-Language-Hearing Association.  He has offered to assist in appealing any inappropriate determinations.

Medicare does not pay for services provided by an assistant or an aide, even if they are registered/supervised by an SLP.  This applies to all health care settings, and cannot be changed by a local coverage determination.  Most private insurers tend to follow Medicare guidelines for reimbursement.   ASHA addresses reimbursement for services provided by SLPAs as an FAQ on their website. Here is the link:

If your employer is unaware of the state and federal regulations of speech assistants/aides, suggest implementing a policy or protocol for use of SLPAs in your facility to avoid any issues that may arise concerning ethics and billing.  Keep in mind this may be a sensitive topic, if employers are currently unaware of the regulations and are using SLPAs to provide therapy at an inexpensive pay rate compared to that of CCC-SLPs.


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