By Brooke Leiman, Katie Gore & Rita Thurman
Dealing with fluency issues can be confusing and frustrating for the client and family. Navigating health insurance reimbursement for stuttering treatment can also present challenges for them. In our extensive work with clients who stutter, we’ve learned several tips for getting treatment covered—either initially or through an appeal if the insurance company denies coverage.
Ease your clients’ and your own anxiety by learning how to navigate through (or around) these four common insurance roadblocks.
Does the policy cover stuttering treatment?
Become familiar with an insurance company’s specified benefits to determine if it will reimburse stuttering evaluation and treatment. Plans that are compliant with the Affordable Care Act cover habilitative and rehabilitative treatments. When a young child begins stuttering at the time that they are developing language, treatment may be covered under habilitation benefits. Habilitative therapy refers to treatment that “helps a person keep, learn, or improve skills,” as opposed to rehabilitation that helps a person regain lost function.
Some policies list stuttering as a specific exclusion, and in this case, an appeal will most likely not result in coverage.
However, certain policy language allows for more leverage. Often a policy states treatment is covered only when it involves “restorative and rehabilitative care or treatment for loss of impairment of speech when the treatment is medically necessary because of an illness, injury or surgery.” This language indicates that treatment for any ICD-10 (International Classification of Diseases, 10th edition) diagnosis code that is “developmental” (including stuttering) will be denied. However, an appeal may result in coverage if you demonstrate that stuttering is developmental AND neurological. For an appeal of this nature, refer to current stuttering research in brain imaging.
For example: There is research to suggest there may be neurological differences between children and adults who stutter and those who do not Stuttering is not a psychogenic, emotional or “involuntary acted condition.” Recent brain imaging studies indicate that, during speech, people who stutter exhibit specific differences in the physiology and functioning of the brain in the areas responsible for speech and language.
What diagnostic codes can I use for a client who stutters?
The ICD-10 identifies four different types of stuttering. If the client presents with a clear diagnosis of the following four conditions, coding them differently for the purpose of obtaining insurance reimbursement is fraud. This is illegal and a violation of the ASHA Code of Ethics.
F80.81 childhood onset fluency disorder
Use this code for children and adults if the onset of stuttering occurred between the ages of 0 to 18 and no neurological incident preceded the onset.
R47.2 fluency disorder in conditions classified elsewhere
This code applies when the client has a medical diagnosis—like Parkinson’s disease—that triggered the onset of stuttering.
I69.023 fluency disorder following non-traumatic subarachnoid hemorrhage
This is the appropriate code when the onset of stuttering occurs after a stroke.
F98.5 adult onset fluency disorder
Used if onset happens after age 18 and no neurological incident preceded the onset. This is also used when disfluencies are tied to psychological diagnoses, such as post-traumatic stress disorder. However, SLPs rarely use this code.
What about “laryngeal spasm” or “other/unspecified” speech disturbance?
Stuttering should not be coded as “laryngeal spasm” or “other/unspecified speech disturbance.”
I’m an out-of-network specialist. Will my client be covered?
Many families spend a considerable amount of time searching for a speech-language pathologist experienced in fluency disorders. When they locate a specialist, however, they might discover the specialist isn’t in-network with their insurance. This is when a “gap exception” might apply.
Gap exceptions mean the specialist gets regarded as an in-network provider for the policy holder. Therefore, your client would pay only their in-network deductible and/or in-network copay/coinsurance for a clinician granted this exception—even if they are considered an out-of-network provider. This allows the client to receive qualified services at a more affordable rate. Insurance companies grant gap exceptions when you can prove the list of local in-network SLPs doesn’t include a stuttering specialist or one experienced in treating fluency disorders.
The process for requesting a gap exception varies among insurance companies, so you will need to contact the specific company to learn more.
Other Authors of this article:
Katie Gore, MA, CCC-SLP, is the founder and director of speech IRL in Chicago. She is co-chair of professional relations on the of the National Stuttering Association board of directors.
Rita Thurman, MS, CCC-SLP, BRS-FD, is in private practice in Raleigh, North Carolina. Her practice focuses on the evaluation and treatment of children, teens and adults who stutter. She also serves on the executive board of the American Board of Fluency and Fluency Disorders.
This article was featured in the ASHA Leader blog and can be accessed here.