Medicare Request for Speech Generating Device (SGD) Funding | Explanation & Elaboration |
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I. Demographic Information | Patient Name
Medicare Number
Date of Birth
Medical Diagnosis
Date of Onset Other helpful information includes:
Patient's contact information
Physician's contact informaiton
SLP's contact information
Patient's primary support contact information
Date of SLP evaluation |
II. Current Communication ImpairmentA. General Statements B. Comprehensive Assessment | 1. Hearing Status This section should explicitly provide information about the person's hearing status as it relates to using a SGD and accessories. If the individual's hearing ability is not an issue, the report can state, "The patient possesses the hearing abilities to effectively use a SGD to communicate functionally." | - Describe communicator's hearing relative to communicating with a SGD (along a continuum from normal hearing to deafness).
- Include communication partner's status, if relevant.
- Include specifics (if related to SGD use/selection) regarding acuity, localization, understanding of natural speech, understanding speech generated by a SGD.
| 2. Vision Status This section should explicitly provide information about the person's visual status as it relates to using a SGD and accessories. If the individual's vision is not an issue the report can state, "The patient possesses the visual abilities to effectively use a SGD to communicate functionally." | - Describe the communicator's vision relative to using a SGD (along a continuum from normal vision to blindness).
- Include the following elements if/when pertinent to SGD use/selection: Acuity, visual tracking, visual field, lighting needs, angle of view, size of symbols, contrast (color, detail) and spacing.
| 3. Physical Status This section should provide information about the person's physical skills and abilities as they relate to using a SGD and accessories. The report should state, "The patient possesses the physical abilities to effectively use a SGD and required accessories to communicate. | - Describe pertinent considerations regarding motor skills, ambulatory status, positioning and seating.
- Describe how person will access the SGD (direct selection, scanning) and the person's switch access requirements.
- Describe if accommodations may be required over time to deal with changes in physical status that will affect access.
| | 4. Language Skills This section should explicitly provide information about the person's language skills and abilities as they relate to using a SGD and accessories. | Describe the level of linguistic impairment (no impairment to severe language impairment) as it relates to the person's ability to use a SGD. Consider describing: - performance on any language assessments completed (e.g., BDAE, WAB, picture description).
- competency or ability to develop functional language skills (e.g., form, content, use).
- type and level of symbol use by the individual. Does person require pictographic symbols, words, letters, and/or a combination of symbols?
- linguistic capacity to formulate language / messages (e.g., whole vs. part)
- level of independence in formulating messages using language.
| | 5. Cognitive Skills This section should explicitly provide information about the person's cognitive skills and abilities as they relate to the use of a SGD and accessories. If the individual's cognitive skills are not an issue, the report can state, "The patient possesses the cognitive/linguistic abilities to effectively use a SGD to communicate and achieve functional communication goals." | - Describe the level of cognitive impairment (no impairment-significant cognitive impairment) as it relates to the person's need for and ability to use a SGD.
- Describe the person's attention, memory, and problem-solving skills as they relate to using an SGD to enhance or develop daily, functional communication skills.
Click Here For Example of Traumatic Brain Injury Cognitive levels (Rancho) Click Here For Aphasia Example |
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III. Daily Communication Needs A. Specific Daily Functional Communication Needs This section should list the person's daily functional communication needs in areas described. Note: It is reasonable to supplement the categories by considering daily communication situations, environments, partners, and specific messages. | Document specific, daily functional communication needs in any of the three areas listed below. - Communication to enable person to get physical needs met.
Click Here for Examples - Communication to enable person to carry out family and community interactions. Click Here for Examples
- Communication to enable person to obtain necessary medical care and participate in medical decision-making.
Click Here for Examples
Note: SLP reports should include a specific reference to all daily communication needs that may involve use of the telephone. Click Here for Explanation |
| B. Ability to meet communication needs with non-SGD treatment approaches: This section should document why the patient is unable to fulfill daily functional communication needs using natural speech (or speech aids) and non-SGD treatment approaches. The report should state, "The patient's daily functional communication needs cannot be met using natural communication methods or low-tech/no-tech AAC techniques because of ______________ (be specific). | - Discuss success of speech therapy (to date and future prognosis) without a SGD.
- Discuss the individual's ability to use low-tech strategies and natural modes of communication to meet daily functional communication needs.
- Discuss why a SGD is required in addition to, or instead of low-tech strategies and natural speech.
- Show explicitly that other forms of treatment have been considered and ruled out.
- Mention issues related to communicating with primary partners and caregivers in specific contexts.
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IV. Functional Communication Goals This section should explicitly state the daily functional communication treatment goals that will be met using a SGD. NOTE: This is a very important section. Functional goals are key to demonstrating the need for ongoing treatment. They are also key to demonstrating positive outcomes with SGD use and why a particular SGD will benefit the individual and enable him / her to achieve functional communication goals. SLPs should prepare immediate term, short-to-mid term and long-term functional goals.
| - List immediate, short term and long term functional communication goals and a timetable for completion of these goals.
- Goals should correspond to specific daily functional communication needs (including specific contexts and communication partners as well as communication functions: e.g. needs, greetings, information exchange, etc.) and illustrate how the patient will benefit from the acquisition of and training on the SGD. Click Here For Examples Of Functional Communication Goals
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V. Rationale for Device Selection This section will explain why certain device features are required based on the person's skills and abilities as described in Section II. This section provides data that leads first to the selection of a specific device code and second, to a specific device within that code, as well as specific accessories. The report should state, "This individual requires a speech generating device with (list specific features) to meet the person's functional communication goals." | In order to make these decisions, SLPs may work with OTs, PTs and Rehab Engineers and use AAC devices, computer or manual simulations and/or clinical trials to gather pertinent data. |
A. General Features of Recommended SGD and Accessories |
| B. Recommended Medicare Device and Accessory Codes Note: There are coverage limitations and issues related to whether a manufacturer/supplier will accept assignment | Refer to the accompanying chart to identify specific codes for SGD categories and accessory categories that will enable the individual to achieve functional communication goals. Click Here For the Table of SGD codes. |
C. Description of equipment and procedures used during any demonstrations of the recommended SGD and any other SGDs and accessories. | Include evidence that the individual was present and actively participated in the assessment process. Discuss assessment outcomes that demonstrate the person's ability to use the SGD and recommended accessories. |
| D. SGD and accessories recommended. The report should state, "The individual's ability to achieve his/her functional communication goals requires the acquisition and use of the (name the device) and (name the specific accessories)." This SGD represents the clinically most appropriate device for (name of beneficiary). | List the specific SGD and accessories and include rationale for why this SGD and any accessories being requested will enable the patient to achieve functional communication goals, as stated earlier in the report. |
| E. Patient/family support of SGD | Discuss participation of the family/caregiver/advocate and state that they agree to the selected SGD and will support the equipment and its use for daily communication. |
| F. Physician involvement statement. The report should say, "This report was forwarded to the treating physician (Name, address, phone number) on ______(date). so that (he/she) can write a prescription of the recommended SGD and accessories." | Note. The date that the SLP forwards the AAC device assessment report should be BEFORE the date on the doctor's prescription. |
VI. Treatment Plan Address all functional communication goals previously stated for the beneficiary and identify the plan for achieving these goals using the SGD and accessories. | a) Frequency of Speech-Language Pathology Treatment
b) Schedule for Functional Goal Achievement - Treatment plan with a training schedule for the selected device and accessories.
- Achievement dates for operational competency
- Achievement dates for functional communication goals
c) Type of Treatment (Individual vs. Group)
d) Projected Frequency of Reassessment
e) Follow-up Requirements for SGD and accessories - individual(s) responsible for programming SGD
- individual(s) responsible for troubleshooting SGD
Click Here For Examples Of Treatment Plans |
VII. Functional Benefit of Upgrade This section is required only if the SLP is requesting an upgrade of equipment. | To upgrade a previously issued SGD, provide information regarding: a) the features or capabilities of the upgrade as compared to existing equipment b) the additional daily functional communication goals the patient can achieve with the upgrade as compared to existing equipment and c) the importance of the patient's ability to achieve functional communication goals. |
VIII. SLP Assurance of Financial Independence and Signature The report should state, "The Speech-Language Pathologist performing this evaluation is not an employee of and does not have a financial relationship with the supplier of any SGD." | Evaluating SLP name
ASHA Certification #
State License #
Disclaimer statement
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