Insurance advise from Marilyn Agin M.D. and Larry Laveman M.D.

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Archive from

Marilyn Agin, M.D.

Medical Director CHERAB Foundation

-Dear Kari, I wanted to respond to your insurance code question for

apraxia. In the ICD 9 medical code book, #315.4 is Dyspraxia Syndrome.

The confusion is that is that many of the #315 codes are

developmental, but not this one. #784.69 is probably the safer code to

use in that it comes from the section where the codes are neurologic.

I am also adding to this a previous post (#263) which further

elucidates this:

One of the forces that most of our families with apraxic children

have had to deal at some time or another is the medical insurers. If a

medical professional or speech pathologist writes a report or a

bill for submssion to the insurance company, here are some

important tenets to follow:

-Oral/verbal apraxia is a neurologic disorder so never use the word

developmental or a code that is " developmental " in the report or

on the bill. -Useful ICD codes for Apraxia of Speech are #315.40 or

#781.3. The latter code is also one used for Hypotonia, Sensorimotor

Integraton Disorder, and Coordinaton disorder, which may be associated

with apraxia of speech.

-If there is an associated expressive language disorder with the

apraxia, which is commonly the case, use #784.6 which is " other

symbolic dysfunction. " If #315.3, 315.31, 315.39, or 315.9 are used,

these are developmental codes and may not be reimbursed.

Often the insurance co. will ask your doctor to write a Letter of

Medical Necessity of Letter of Predetermination. This needs to state

the appropriate diagnosis and code number, state that the

diagnosis(ses) have a neurologic basis and are not developmental, and

intensive treatment by qualified, experienced speech and

occupational therapists is required. Often you need to state the

specialized nature of the therapy (PROMPT, oromotor, sensory

integration, etc.) and explain why your therapist is more qualified

than the one who is " in network " for provider. Have your therapists

state their specialized credentials and certifications.

-Define apraxia as a speech disorder where the brain signals that go

to the muscles and structures of the speech mechanism are

disrupted.

-Without therapy, children do not outgrow apraxia of speech. Speech

therapy is needed at least 4x week by experienced oral motor speech

therapists. Without this therapy, prognosis for improvement is poor.

-The provider may only provide therapy for 2 months or 6 months

of therapy. Accept it and reapply with new goals set by your speech

pathologist.

Don't be discouraged by a rejection. That's what they want, They

want to wear you down, but don't let them. This is your child and

you have to continue the fight and go to the top person in the plan.

If they tell you this is a preexisting condition, this is absolutely

absurd when talking about a child.

Be advised though, that some insurers are better than others. Some

will never offer speech services unless your child has had a stroke or

accident. (What a horrible thought). If you have a choice of insurers,

make sure you choose one wisely. Look at the benefits before you sign

up.

Good luck!

Marilyn Agin, M.D.

Medical Director CHERAB Foundation

http://www.apraxia.cc

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Archive from

Larry Laveman, MD

Medical Consultant, CHERAB

Hi Kari:

The code 315.4 generally refers to motor delays, and indicates a

developmental origen (the 315 prefix is used for developmental and

learning disorders).

Codes beginning with 7 generally refer to signs and symptoms, and

most doctors and therapists are advised by their coding gurus to

avoid them, as they can sometimes cause reduced reimbursement (we all

want to get paid fairly...).

Some insurances may not recognize the 784.69 code, and reject the

claim on this basis. I am cautious in my practice to always give

multiple dx codes, describing the full symptom complex of the child.

Larry Laveman, MD

Medical Consultant, CHERAB

http://www.apraxia.cc

> Hi, I was just wondering if you could tell me where

> you found the explanations for the insurance codes? I

> just went to a website to see what the codes were that

> are being billed to my insurance, it just happens that

> ICD-9 website, it says that 315.4 is a developmental

> delay... and apraxia is 784.69 according to that

> place. I would really appreciate any help, I am

> trying to find out exactly what and why they are

> billing it to my insurance that way when he has a dx

> of apraxia. Thanks!

>Kari Belle

>http://www.SouthernCaliApraxia.homestead.com