SECTION 6:
PROPOSED COVERAGE CRITERIA FOR AAC DEVICES

PROPOSED WORDING FOR AAC DEVICE NATIONAL COVERAGE DECISION

Augmentative & Alternative Communication Devices

HCPCS Codes:

Equipment:

E xxx 1 AAC devices with digitized speech output

E xxx 2 AAC devices with synthesized speech output, which require message formulation by spelling and device access by physical contact direct selection techniques

E xxx 3 AAC devices with synthesized speech output, which permit multiple methods of message formulation and multiple methods of device access

Accessories:

E xxx 4-1 AAC Accessories: access technologies, direct and indirect

E xxx 4-2 AAC Accessories: mounting systems

E xxx 4-3 AAC Accessories: carrying cases

E xxx 4-4 AAC Accessories: power supplies

E xxx 4-5 AAC Software

HCPCS Modifiers for AAC devices with digitized speech output

ZV AAC devices with digitized speech output with less than 4 minutes recording time

ZW AAC devices with digitized speech output with 4- 8 minutes recording time

ZX AAC devices with digitized speech output with 9-16 minutes recording time

ZY AAC devices with digitized speech output with 17-32 minutes recording time

ZZ AAC devices with digitized speech output with more than 32 minutes recording time

Benefit Category Durable Medical Equipment

Definitions:

Augmentative & Alternative Communication (AAC) devices are electronic devices that provide treatment for severe dysarthria, apraxia of speech, or aphasia, when, due to those communication impairments, an individual is not able to meet the communication needs that arise in the course of current and projected future daily activities. AAC devices are covered as durable medical equipment when incorporated into a speech language pathology treatment plan, and when it is determined by a speech-language pathology assessment that an individual is unable to meet the communication needs arising in the course of daily activities using natural communication techniques.

AAC devices include electronic devices that are: a) dedicated communication devices; and b) portable computers that have been modified to serve as an individual’s communication device. The term AAC accessories means device-related components, software, and accessories that are necessary additions to an AAC device, based on the nature and severity of the beneficiary’s disability, to permit its effective and efficient use.

An AAC device will be covered by Medicare as an item of durable medical equipment when all of the following are met: a) the AAC device is recommended by a speech-language pathologist in a narrative report based on a complete assessment; b) it is incorporated into a speech-language pathology treatment plan stating the functional communication goals to be achieved with the AAC device; c) it is prescribed by the beneficiary’s physician; and d) it is supported by a completed certificate of medical necessity.

Coverage and Payment Rules

Code E xxx1 is covered if the patient meets:

a. criteria 1-3 but not

b. criteria 4, 5 and 6

Code E xxx2 is covered if the patient meets:

a. criteria 1-5 and 7 but not

b. criteria 6, 8, and 9

Code E xxx3 is covered if the patient meets:

a. criteria 1-3 and

b. criteria 4 and 6

Clinical Criteria:
  1. The individual has a communication disability with a diagnosis of severe dysarthria, apraxia, and/or aphasia.
  2. The individual’s communication needs that arise in the course of current and projected daily activities cannot be met using natural communication methods.
  3. The individual requires a speech output communication device to meet his/her functional communication goals.
  4. The individual possesses the linguistic capability to formulate language (messages) independently.
  5. The individual will produce messages most effectively and efficiently using spelling.
  6. The individual will require an AAC device with extensive language storage capacity and rate enhancement features.
  7. The individual will access the AAC device most effectively and efficiently by means of a physical contact direct selection technique, such as with a finger, other body part, stylus, hand held pointer, head stick or mouth stick.
  8. The individual will access the AAC device most effectively and efficiently by means of an electronic accessory that permits direct selection.
  9. The individual will access the AAC device most effectively and efficiently by means of an indirect selection technique (e.g., scanning, Morse Code).

The speech-language pathologist’s narrative report also must establish whether an individual for whom HCPCS Code E xxx 1-3 will require any AAC accessories.

For accessory code E xxx 4-5 to be covered, the patient must meet criteria 4 and 6 as listed above, and the certificate of medical necessity must specifically establish that the individual has access to specially adapted computer components and adaptations that will permit the individual’s needs to be met solely by the use of AAC software.

Appropriate use of the Z_ modifier is the responsibility of the supplier billing the DMERC. This modifier identifies the device that fits within the HCPCS code Exxx1.

 

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