What CPT codes are used for speech therapy evaluations?

Use 92521 (fluency evaluation), 92522 (speech sound production), 92523 (speech sound production with language comprehension/expression), 92524 (behavioral voice analysis), or 92610 (swallowing evaluation). Treatment uses 92507 (speech/language treatment), 92526 (swallowing treatment), and 97129/97130 (cognitive function intervention). Document specific deficits to support code selection.

What documentation supports medical necessity for speech therapy?

Document: diagnosis causing impairment (CVA, TBI, Parkinson's, head/neck cancer), specific functional deficits (aspiration risk, communication breakdown, cognitive-linguistic deficits), objective test scores or severity ratings, prior level of function, prognosis, and skilled intervention rationale. Medicare requires therapy to be reasonable and necessary with expectation of improvement.

How should dysphagia evaluation be documented?

Document: clinical swallow evaluation findings (oral motor exam, trial swallows with various consistencies), signs of aspiration (coughing, wet vocal quality, oxygen desaturation), diet recommendations (IDDSI levels), compensatory strategies taught, and instrumental study indication if needed (FEES or MBSS). Specify aspiration risk level and diet texture modifications.

What cognitive-communication documentation is required?

Document: specific cognitive domains assessed (attention, memory, executive function, problem-solving), standardized test scores when applicable, functional impact (safety awareness, medication management, communication competence), and treatment goals with measurable outcomes. Use 97129 for initial 15 minutes and 97130 for additional 15-minute increments.

How should speech therapy goals be written for Medicare compliance?

Goals must be: measurable (accuracy percentages, independence levels, cueing requirements), functional (relate to daily activities), time-bound (target dates), and skilled (require SLP expertise). Example: 'Patient will safely swallow thin liquids using chin tuck with 90% accuracy for safe hydration in 4 weeks.' Avoid vague goals; specify criteria for success.

Speech Therapy Evaluation Template - SLP Assessment

Speech Therapy — Evaluation Template

Rehabilitation Speech Therapy Updated: 1/3/2026

The Speech Therapy Evaluation Template is designed for Speech-Language Pathologists (SLPs) evaluating patients for speech, language, cognitive-communication, or swallowing disorders (dysphagia). This template documents receptive/expressive language, speech motor function, voice quality, cognitive status, and swallowing safety. Supports Medicare requirements for functional reporting and goal setting. Ideal for outpatient clinics, hospitals, and SNFs.

Quick-Use Checklist

Use this checklist before finalizing documentation.

Confirm visit context, chief concern, and date/time of service before note completion.

Capture required exam/findings and plan elements that support coding specificity.

Document medical decision making clearly to reduce denials and audit risk.

Patient Information

Date: [Date]
Visit Type: Initial Evaluation
Ref Physician: [Name]
Diagnosis: [Medical Diagnosis - e.g., CVA, Parkinson's]
Treatment Diagnosis: [SLP Diagnosis - e.g., Dysphagia, Aphasia]

Subjective

Chief Complaint: [Difficulty swallowing, slurred speech, memory loss] History: [Onset date, mechanism, prior level of function] Communication Needs: [Wants to communicate with family, safety needs]

Objective (Assessment)

Hearing: Screened (Pass/Fail) / Prior hearing loss Speech Motor:

Oral Mech Exam: [Strength/ROM/Symmetry of lips, tongue, jaw]
Articulation: [Intelligibility % in context]
Voice: [Quality, loudness, pitch]
Fluency: [Disfluencies present?]

Language:

Receptive: [Following commands, Yes/No questions]
Expressive: [Naming, Repetition, Conversation]

Cognition:

Attention: [Sustained, Selective]
Memory: [Immediate, Short-term]
Problem Solving/Executive Function: [Safety judgment]

Swallowing (Clinical Bedside Swallow):

Oral Phase: [Bolus formation, transit]
Pharyngeal Phase: [Hyolaryngeal excursion, s/s aspiration]
Trials:
Thin Liquids: [Results]
Nectar/Honey: [Results]
Puree/Solids: [Results]

Assessment

Impression: Patient presents with [Severity] [Diagnosis] characterized by [Deficits]. Prognosis is [Good/Fair/Poor] based on [Factors]. Functional Limitation: Identifying safety risks and communication breakdown.

Plan of Care

Frequency: [X] times per week for [X] weeks. Interventions:

[Dysphagia Therapy - 92526]
[Cognitive Therapy - 97127]
[Speech/Language Tx - 92507]

Goals:

1. Patient will tolerate [Diet consistency] without s/s of aspiration in [X]% of trials.
2. Patient will use compensatory strategies for [Memory/finding words] with [Level] cues.
3. Patient will increase intelligibility to [X]% with unfamiliar listeners.

Speech Therapy — Evaluation Template

Quick-Use Checklist

Template

Patient Information

Subjective

Objective (Assessment)

Assessment

Plan of Care

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