Pediatric Coding Alert

Question: During a preventive visit, our provider noticed that the 2-year-old patient had slightly delayed speech development compared to their peers. The provider recommended a speech therapy evaluation to further assess speech and language skills. What kind of documen­tation is required to show medical necessity for this referral?

Massachusetts Subscriber

Answer: While proving medical necessity isn’t an exact science, you generally want to adhere to the “accepted standards of medical practice,” as stated by the AMA, and show the referral was “reasonable and necessary for the diagnosis or treatment of illness or injury,” as stated by Medicare. To demonstrate medical necessity for the scenario you outline above, the healthcare provider should document the following:

• A detailed description of the child’s speech and language development, including any observed delays or concerns.
• A comparison of the child’s speech and language skills to age-appropriate developmental milestones.
• Any relevant family history or risk factors that may contribute to speech and language delays, such as a family history of speech disorders or a history of ear infections.
• The impact of the speech delay on the child’s daily functioning, social interactions, and overall quality of life.
• A clear explanation of why the speech therapy evaluation is necessary to further assess and address the child’s speech and language development.