Eli's Rehab Report

Published on Wed Jan 20, 2010 PDF

Question: I am a speech-language pathologist in private practice who specializes in pediatrics, and we're having issues with insurance companies denying claims for swallowing therapy. The insurance companies have been telling us that our diagnoses indicate developmental issues, but we're billing with valid swallowing diagnosis codes: either 787.21 or 787.22. How do insurance companies determine from those diagnosis codes that our patients are experiencing developmental delay? We generally have not had any other primary or secondary diagnoses on these claims either.

-- Nevada subscriber

Answer: What you're describing is an unusual denial, especially for swallowing therapy. Insurance companies are more likely to deny a claim due to developmental delay over speech therapy. And experts would contend that a swallowing disorder is almost never developmental.

Chances are, whoever is dealing with your claims is uninformed. Possibly even the policy is flawed.

Best advice: After ensuring you have solid documentation and that nothing else is technically wrong with your claims, contact the insurance company to describe what dysphagia is, and explain that it's not a condition that your patient will outgrow.

You might also try enlisting the help of a physician who frequently refers these cases to you so that he or she can also explain that these cases are not just immature swallowing patterns -- that you're treating an actual disorder that's interfering with the child's growth and development.

Finally, if you have any secondary diagnoses, these also could help. For example, perhaps the child has low tone or cerebral palsy. Bottom line, you have a great argument if you can talk to the right person at the insurance company.