Dr. Agin's Insurance repost (yet again)

[Guest guest]

From: " Marilyn Agin M.D. "

Date: Thu Nov 29, 2001 11:46 am

Subject: Re: insurance (repost)

From: Marilyn Agin M.D.

-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

--- In @y..., " feathrstone " <jatterrell@w...>

wrote:

> I'm new to the group and trying to find my way around. How do I

find a post? I'd like more information on the insurance and the

codes?

>

> Terry