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Medicare Funding of AAC Devices - Definitions and Examples


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Dysarthria/Anarthria - % intelligible, speaking rate.

Aphasia - scores on receptive and expressive language tests.

Apraxia - motor planning/execution score on apraxia tests

Aphonia - inability to produce voice naturally (due to a physical impairment) and/or inability to produce voice by using a speech prosthesis (e.g., Passy-Muir valve, electrolarynx, tracheoesophageal puncture) due to physical disability.

Examples of statements regarding current status and expected course:

a) Patient has severe dysarthria due to cerebral palsy. The condition is stable and speech intelligibility is not expected to improve.

b) The patient has severe dysarthria due to amyotrophic lateral sclerosis. Currently speech rate is ### (half of normal), indicating an expected precipitous decline in intelligibility. Speech intelligibility will continue to deteriorate. This patient will require the use of a SGD throughout the course of this disease.

c) The patient's aphasia is (e.g., stable & chronic, progressive) in nature. Verbal expression is expected to (improve, not improve, deteriorate).

Staging scales for speech intelligibility:

Severe dysarthria due to Amyotrophic Lateral Sclerosis:

Stage 1: No detectable speech disorder
Stage 2: Obvious speech disorder, inte:lligible
Stage 3: Reduction in speech intelligibility
Stage 4: Natural speech supplemented with SGDs
Stage 5: No useful speech (SGD only)

Severe dysarthria due to Guillian-Barre Syndrome:

Stage 1. Deterioration phase
Stage 2. Loss of Speech
Stage 3. Prolonged Speechlessness
Stage 4. Spontaneous Recovery of Speech
Stage 5. Long-term Residual Motor Speech Disorder

Severe dysarthria due to Brainstem CVA:

Stage 1. No Useful Speech
Stage 2. Reestablish Subsystem Control for Speech
Stage 3. Independent Use of Natural Speech
Stage 4. Maximize Speech Naturalness & Efficiency
Stage 5. No Detectable Speech Disorder

Aphonia due to oral/trach ventilator dependence:

Stage 1. No useful speech
Stage 2. Reestablish Subsystem Control for Speech
Stage 3. SGD Supplemented Use of Natural Speech
Stage 4. Maximize Natural Speech Efficiency, Effectiveness
Stage 5. No detectable Speech Disorder

Language assessment tool examples:

Boston Diagnostic Aphasia Examination
Western Aphasia Battery

Rancho Los Amigos Cognitive Levels for TBI:

1. No response
2. Generalized response
3. Localized response
4. Confused-agitated
5. Confused, inappropriate (non-agitated)
6. Confused-appropriate
7. Automatic-appropriate
8. Purposeful & appropriate

Hagen C., Malkmus D., Durham P (1979).

Aphasia example:

(Aphasia): Mr. Smith's attention, memory, and nonverbal problem-solving skills are within functional limits. He sustained attention for a two-hour evaluation, recalled how to turn on and off a SGD (after initial instruction), and independently navigated between two pages on a SGD. He has the attention, memory, and problem-solving skills to use an SGD device to achieve his functional communication goals.

Communication to enable a person to get physical needs met:

Ability to communicate in emergency situations, directing behavior of caregivers, advocating for him/herself, communicating with family, friends or clergy using the telephone.

Communication to enable person to carry out family and community interactions:

Communicating to participate in family decision-making, communicating to participate in family leisure activities, communicating with extended family by telephone, attending and participating in support groups, participating in day treatment activities.

Communication to enable person to get necessary medical care and participate in medical decision-making:

Reporting medical status and complaints, asking questions of medical providers, responding to medical provider's questions, discussing choices for end of life care, communicating with medical providers by phone.

Explanation about including reference to use of the telephone

Requiring communication by telephone provides strong support for the ultimate conclusion that an individual requires an SGD. An individual cannot use the telephone using writing, gesture, or sign. Also, if the individual's speech ability is not sufficiently intelligible to be understood by a communication partner in typical telephone communication, no alternative exists but an SGD to address this daily communication need.

Examples of functional communication goals:

The RMRP requires the SLP to identify functional goals as part of the assessment report. Functional goals are defined in other Medicare guidance as stating the " level of communicative independence the patient is expected to achieve outside the therapeutic environment." The guidance continues in simpler terms: Functional goals should reflect "the final level the patient is expected to achieve, are realistic, and have a positive effect on the quality of the patient's everyday functions. [Medicare Hospital Manual, 446(a)(3)(A); Medicare Intermediary Manual, 3905,3(a).]

Medicare guidance states the functional goals for speech-language pathology treatment should be designed to achieve "optimum communication independence." The actual level of independence will be individualized. Medicare guidance gives examples of how different levels of performance can be described: Ability to communicate (a) basic physical needs and emotional status, (b) self-care needs, (c) engage in social communicative interaction with immediate family or friends, (d) carry out communicative interactions in the community.

The SLP must consider functional goals as being achievable over a period of time. Some goals may be achieved immediately, while others can be achieved only after time passes or some training is provided. The SLP report should identify three sets of functional goals: immediate, short term and long term, and state the level of training or other services required to achieve these goals. Examples of functional goals include:

  • Mr. ____ will independently communicate physical needs and emotional status to his wife on a daily basis, as needed.
  • Ms. ____ will describe her physical symptoms and ask any questions when interacting with her physician and other health care professionals as needed.
  • Mrs. ____will engage in social communication exchanges with immediate family and extended members in person and by use of the telephone.
  • Mr. ____ will engage in social communication exchanges with friends at home and in other settings.
  • Mrs. ____ will be able to ask questions and provide responses in community-based transactions, such as ordering a meal in a restaurant.
  • Mr.____will instruct his/her caregiver on the proper transfer protocol for moving from wheelchair to the car.
  • Mr.____will communicate by telephone with family, information sources and service providers.

Direct Selection:

  • Keyboard/Display: dynamic/static, number of keys/locations
  • Activation Type: touch sensitive, pressure sensitive, adjustable
  • Optical pointer, eye gaze, other (specify)


  • Display: number of keys, dynamic/static
  • Mode: visual, auditory
  • Type of Scan: linear, row-column, group-row column directed (joystick, trackball), adjustable speed
  • Switch: type (pressure, feedback), position, mount

Encoding Type:

  • Position,
  • Category,
  • Semantic compaction,
  • Numeric,
  • Alphabetic,
  • Morse code,
  • Other (specify)

Type of Symbols:

  • Tactile
  • Pictures: note quality, color vs. black & white
  • Symbols: commercially available, individualized
  • Words, phrases, letters
  • Other (specify)

Storage Capacity:

  • Message length needed
  • Need to maintain files of messages
  • Number of different messages being stored or formulated
  • Other (specify)

Vocabulary Expansion and Rate Enhancement Techniques:

  • Screens or levels
  • Word prediction
  • Other (specify)

Reference Information

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