July - August 1999

September - October 1999

Volume 12

Numbers 4 and 5

UpfrontMaking a difference for people whorely on AAC: The Medicare story

For ConsumersMedicare coverage of AAC devices

The AAC-RERCDissemination and training

Clinical NewsAAC assessment: Clinical decisionmaking and clinical indicators

EquipmentAAC device categories

GovernmentalProposed National Coverage Decisionfor AAC Devices

On the Webhttp://www.AugComInc.com

Continued on page 2

I know of no country where every-one who needs AAC services anddevices can get them. Despiteremarkable progress and a plethoraof favorable laws and public policiesin nations around the world, fundingstreams for AAC devices continue tobe clogged. This issue tells ofongoing efforts in the United States(U.S.) to enable people who needAAC devices to get them. Eachsection summarizes and excerptsinformation submitted to the HealthCare Financing Administration(HCFA), the governmental agencythat administers the Medicareprogram. This information wasprepared by a working group ofAAC professionals to expediteHCFA’s review of the existingMedicare policy which currentlydenies AAC device coverage. Whilethe information is clearly crucial forAAC professionals and people whorely on AAC in the U.S., others fromthe international AAC communitywho are working to tear downfunding barriers may also find ithelpful.

Background

Medicare, the largest health careprogram in the United States, servesmore than 38 million adults over theage of 65, including many adultswith disabilities, both developmentaland acquired. Eligibility is based onage and/or health status, not onincome level. More than 14 percent

of the U.S. populationuses Medicare to meettheir health care needs.A current Medicareguideline states that

AAC devices are “conve-nience items.” This means thatMedicare does not buy AAC devicesfor its beneficiaries unless they (1)submit a claim for an AAC device;(2) receive a denial; (3) appeal thedenial and (4) carry through with athree-tiered administrative appealsprocess. Over the past two decades,Medicare has funded one CanonCommunicator, a RealVoice, oneLightWriter, EZ-Keys software, aMacaw and a Vanguard. To date,every appeal filed for an AACdevice or AAC software has beendecided in favor of the Medicarebeneficiary. However, the fact thatonly six appeals have been filedshows that people in need of AACdevices are not inclined to take partin this tedious process.

The AAC community acts

In November 1997, a workinggroup of AAC professionals con-vened in Boston and developedstrategies to tear down the barriersrestricting access to speech outputcommunication devices for individu-als who rely on Medicare for theirhealth care needs.1 The goal was toget HCFA to replace the existingguidance with a professionally andprogrammatically sound nationalcoverage standard for AAC devicesin the U.S.:

Strategy #1: Ask for the evidenceStrategy #1: Ask for the evidenceStrategy #1: Ask for the evidenceStrategy #1: Ask for the evidenceStrategy #1: Ask for the evidence.HCFA was asked to provide the recordsit relied on when it wrote the existingMedicare guidance decision in the

mid-1980s. The agency reported it wasunable to locate any records at all. Inaddition, the agency admitted it neverconducted a review of the AAC orspeech-language pathology (SLP)medical literature before the guidelinewas issued. Thus, HCFA admitted ithas no rationale for the existingguidance on AAC devices.

Strategy #2:Strategy #2:Strategy #2:Strategy #2:Strategy #2: Use political pressureUse political pressureUse political pressureUse political pressureUse political pressure.Because AAC devices are needed byrelatively few people compared to themillions of individuals who are eligiblefor Medicare, a strategy was needed toraise the visibility of AAC devicecoverage within HCFA. To accomplishthis, a lobbying effort was initiated tosecure the support of key U.S.Senators and Congressman (those oncommittees that oversee HCFA) and tohave them write to HCFA about theneed to review its existing guidancerelated to AAC devices. Ultimately,more than a dozen members of

1

Upfront, Continued from page 1

Congress submitted such letters, as didcoalitions of disability organizations.

Strategy #3Strategy #3Strategy #3Strategy #3Strategy #3: Increase the number ofIncrease the number ofIncrease the number ofIncrease the number ofIncrease the number ofappeals using existing proceduresappeals using existing proceduresappeals using existing proceduresappeals using existing proceduresappeals using existing procedures.Medicare beneficiaries and SLPs wereencouraged to treat Medicare as an“inefficient payer,” rather than as“broken,” and to use the existingprocedures to try to obtain funding forAAC devices. As more claims wereapproved, evidence of claims beingmired down in a slow administrativeappeals process increased. TwoMedicare booklets are now available toassist clinicians in preparing a requestfor AAC device funding.2

Strategy #4Strategy #4Strategy #4Strategy #4Strategy #4: Educate fundersEducate fundersEducate fundersEducate fundersEducate fundersregarding the functional benefits ofregarding the functional benefits ofregarding the functional benefits ofregarding the functional benefits ofregarding the functional benefits ofAAC devicesAAC devicesAAC devicesAAC devicesAAC devices. Meetings were held withthe regional Medicare medicaldirectors and with Medicare centraloffice staff to educate them aboutAAC devices and to allow them toidentify any concerns they might haveregarding Medicare coverage of AACdevices.

HCFA responds

In June 1999, HCFA contactedLewis Golinker, an attorney andlongtime advocate for people withAAC needs, and provided notice thatMedicare was now prepared toreview its national coverage policyfor AAC devices. HCFA staff askedfor specific information and prom-ised to review a request for coverageof AAC devices within 90 days ofits submission.

Over the next six months, aworking group of AAC professionalscollected, compiled and, wherenecessary, developed informationfor the Formal Request for an AACDevice National Coverage Deci-sion.3 The document consists of 100pages of narrative and a 12 inchstack of appendices. The FormalRequest was delivered to HCFA onDecember 30, 1999, on behalf of 13organizations that represent theinterests of Medicare beneficiaries,service providers, AAC devicemanufacturers and advocates.4

This issue of ACNsummarizes and, in somecases, excerpts clinicallyimportant elements of thisdocument. For Consum- For Consum- For Consum- For Consum- For Consum-ersersersersers addresses the medical condi-tions requiring AAC devices andcites efficacy and outcomesstudies. The AAC-RERC The AAC-RERC The AAC-RERC The AAC-RERC The AAC-RERC sectiondescribes the Center’s role indisseminating information. TheClinical News Clinical News Clinical News Clinical News Clinical News and EquipmentEquipmentEquipmentEquipmentEquipmentsections highlight informationdeveloped specifically for theFormal Request to guide speech-language pathologists through theAAC assessment process. In-cluded are: (1) a six-step AACclinical decision making para-digm, (2) nine clinical indicatorsthat lead to AAC device andaccessory recommendations and(3) three categories of AACdevices and five categories ofAAC accessories that are techno-logically and clinically unique.Governmental Governmental Governmental Governmental Governmental contains theverbatim text of the proposedNational Coverage Decision.Finally, On the Web On the Web On the Web On the Web On the Web announcesthe ACI website [http://www.AugComInc.com] where you can,among other things, access theentire 100-page narrative of theFormal Request for an AACDevice National CoverageDecision.

Sarah W. Blackstone, Ph.D.,CCC-SP

Medicare coverage of

AAC devices

AAC treatment is widely accepted byhealth benefits funding programsand should be covered by Medicare.However, according to existingMedicare guidance, AAC devices anddevice accessories, which are stan-dard and preferred treatment for thefunctional communication difficul-ties associated with severe dysar-thria, apraxia of speech and/oraphasia, are not covered.

The HCFA staff (see UpfrontUpfrontUpfrontUpfrontUpfront)asked the working group to provide:(1) a description of the diseases/conditions that underlie the need forAAC devices; (2) copies of theefficacy and outcomes studies thatshow AAC devices to be effectivetreatment and (3) an estimate of thenumber of Medicare beneficiarieswho could benefit from AAC devices.

Who can benefit?

In preparing the Formal Requestfor Coverage of AAC Devices, theMedicare working group demon-strated that SLPs routinely recom-mend AAC devices as a componentof treatment for individuals withdysarthria, apraxia of speech and/oraphasia so severe they are unable tomeet their communication needsthrough natural modes of communi-cation. AAC devices can enable theseindividuals to achieve their func-tional communication goals, be theythe expression of simple wants andneeds or the communication ofcomplex thoughts and ideas acrossmultiple settings.1. People with Dysarthria. 1. People with Dysarthria. 1. People with Dysarthria. 1. People with Dysarthria. 1. People with Dysarthria. TheFormal Request describes dysarthriaas a group of motor disorders that

2

Continued on page 4

affects the ability of the vocal organsto execute the movements required toproduce intelligible speech. Dysar-thria interferes with speech intelligi-bility and is characterized by prob-lems with articulation (production ofspeech sounds), voicing (volume andquality of speech) and prosody(speech rate, rhythm and natural-ness). The causes of severe dysar-thria and anarthria (no speech)include the degenerative, acquiredand congenital neurological condi-tions listed in Table I.5 The type,prevalence and course of dysarthriavaries with the condition.

AAC devices are widely recog-nized as efficacious treatment forindividuals at Stages IV or V on theDysarthria Rating Scale.5 TheFormal Request cites the position ofthe National Joint Committee on theCommunicative Needs of Personswith Severe Disabilities that AACdevices are appropriate treatment forpeople with severe communicationimpairments.6 It also references theALS Care Consensus Conferencewhich recommends AAC devices astreatment for the speech lossesassociated with ALS.7

2. People with apraxia2. People with apraxia2. People with apraxia2. People with apraxia2. People with apraxia. Acquiredapraxia of speech is defined as aspeech disorder resulting from injuryto the brain. It is a deficit in the

planning and programming ofmovement sequences for speech, andoccurs despite the normal movementof the same muscles when speech isnot involved. Apraxia of speech ischaracterized by changes in articula-tion and prosody. The most commoncause of apraxia is stroke, althoughapraxia of speech also occurs withtumors or traumatic brain injuries.As a clinical entity, apraxia isdefined and distinguished fromaphasia and dysarthria. However,severe apraxia almost always co-occurs with aphasia. AAC strategiesand devices are effective treatmentfor some people with severe apraxiaof speech.3. People with aphasia3. People with aphasia3. People with aphasia3. People with aphasia3. People with aphasia. Languageand communication skills arepermanently altered as a result ofsevere aphasia. Aphasia is caused bybrain damage typically involving thelanguage-dominant cerebral hemi-sphere. By far the most commoncause of aphasia is stroke, althoughaphasia may also result from braintumors, head injuries or other insultsto areas of the brain that mediatelanguage processing.

With severe aphasia, individualsmay not regain sufficient verbalcommunication skills to participatefully in adult communication

activities, e.g., talking with familymembers, conducting transactions inthe community or sharing lifeexperiences with others. Becausesuch limitations result in socialisolation, restricted activity andlesser autonomy,

8,9 individuals with

severe aphasia can benefit fromusing AAC devices that enable themto communicate functional needsmore specifically, participate insocial exchanges, become moreindependent in the community, talkon the telephone, communicatemedical or emergency informationand provide other information.

Efficacy and outcomes

HCFA staff requested copies of allpublished research articles frommedical and allied health journalsthat confirm the efficacy of usingAAC devices to treat severe dysar-thria, apraxia of speech and aphasia.The working group scoured theliterature and found outcomes andefficacy studies that clearly demon-strate the effectiveness of AACdevices with people with theseconditions.

10 Without these data, the

HCFA staff would not have consid-ered the Formal Request.1. Dysarthria. 1. Dysarthria. 1. Dysarthria. 1. Dysarthria. 1. Dysarthria. The research thatdocuments the impact of AAC

3

Table I. Characteristics of dysarthria among people with diseases/conditions that may require AACAdapted from Yorkston et al. (1999)5

devices on individuals with dysar-thria reports on the efficacy of thetreatment and the outcomes forindividuals with various conditions.Degenerative conditions

♦ Amyotrophic lateral sclerosis(ALS): In a retrospective chartreview of treatment data for 126persons with ALS (61 males; 65females), 72% of the men and73% of the women had receivedsome kind of AAC treatment.However, the type and nature oftreatment seemed to vary bygender. Women used low-techoptions (e.g., alphabet boards)three times as often as men(women=20%; men=6%). Womenalso reported using speech outputdevices more than men(women=49%; men=26%).However, men used AAC devicesfor both written and spokencommunication more often thanwomen (men=35%;women=12%).11

In a consumer satisfaction study,Mathy found that individuals withALS have a generally high level ofsatisfaction with their AACdevices. On a seven-point scale(with 1 being least satisfied and 7being most satisfied), ratingsranged from 5 to 7. Subjects weremore satisfied with their ability tocreate, store and retrieve lengthymessages to express needs/wantsand exchange information withfamily and care providers thanthey were with using AAC devicesas a means to conduct conversa-tions (average rating 4).12

Books, articles, TV programs andpersonal websites offer a host ofpersonal stories by or aboutindividuals with ALS, who useAAC devices. Perhaps the mostwell known author is the physi-

cist, Dr. Stephen Hawking. Thesestories make it clear that no onereally “wants” to use an AACdevice; rather, the AAC device isa “lifeline to the world.”13

♦ Multiple Sclerosis (MS): In a1992 survey of 656 persons with adiagnosis of MS, researchersreported that 23% had speechdeficits. However, only 4% (26people) had such severe dysar-thria that strangers could notunderstand them. Of those, onlyseven people (fewer than 2% ofthe 656 individuals with MS) hadused an AAC device.14

♦ Parkinson’s Disease: Whilestudies demonstrate the effective-ness of delayed auditory feedbackdevices, the working group wasunable to find published studiesdescribing the use of speechoutput devices with this popula-tion, despite personal knowledgeof examples.

Acquired and congenital conditions

♦ Locked-in Syndrome: Culp andLadtkow followed a series of 16individuals with locked-in syn-drome for a year or more. Theydocumented the use of AACtechniques ranging from minimaleye movements to the successfuluse of computerized AACdevices. At follow-up, 80 percenthad pursued electronic communi-cation options. Half were usingdirect selection AAC devices andhalf relied on visual or auditoryscanning techniques. 15

♦ Cerebral Palsy: Outcome studieshave documented a variety of

functional effects, includingincreased participation in conver-sations,16 spontaneously initiatedrequests,17 and increased percent-age of time AAC devices areused.18 In an 1987 survey of 66dysarthric adults with cerebralpalsy, LaFontaine & DeRuyterfound that more than half (58%)were using simple augmentativecommunication systems andaccessing them through directselection (62%).19

♦ Traumatic Brain Injury (TBI):Dysarthria generally resolvesduring the early and middlestages of recovery after TBI.However, a small number ofindividuals continue to requireAAC devices to participateeffectively in their rehabilitationprograms and to meet ongoingcommunication needs.20,21

Ladtkow and Culp reported on132 individuals with TBI over an18 month period. Approximately20 percent were “nonspeaking” atsome point during their recovery.Of these, 55 percent regainedfunctional speech during the first18 months. Less than ten percent(n=12) used AAC after the first 18months.22

2. Apraxia2. Apraxia2. Apraxia2. Apraxia2. Apraxia. A number of casestudies describe the efficacy of AACdevices with people who have severeapraxia of speech.

♦ An early case report describedthree individuals who usedspeech output devices. Onewoman, who prior to AACintervention would not leave herhome, learned to use an AACdevice and returned to many ofthe activities she engaged inpremorbidly. She consideredherself “communicatively inde-pendent” as a result.

23

♦ Yorkston & Waugh described an

For Consumers, Continued from page 3There is a critical need

for the AAC community to

document the successful

use of AAC devices.

4

Continued on page 6

individual who was unable toformulate an adequate yes/noresponse using natural speech orgestures. She learned to use anAAC device to indicate “yes” and“no.”24

♦ A 47-year-old interior designer,who experienced a stroke withsevere apraxia and moderateaphasia progressed throughtraditional speech therapy to amulticomponent, nonelectronicAAC system. Three years poststroke, when he wished to returnto work, an AAC device pro-grammed with conversationalcontrol phrases allowed him toinitiate, direct and terminateconversations with his clients.25

♦ Rogers described a five-yeartrajectory of communicationimpairment wherein speechsymptoms progressed fromapraxia to severe aphasia. Treat-ment strategies involved theidentification of topic and keywords, gestural and drawingsystems, a communication bookand an AAC device with symbol-based, pre-selected messages.26,27

3. Aphasia3. Aphasia3. Aphasia3. Aphasia3. Aphasia. AAC devices are shownto be appropriate treatment for somepersons with severe aphasia.28,29

According to Fox and Fried-Oken,outcome studies in AAC and aphasiafall into four broad classifications:comprehensive case studies, carefullycontrolled single-case experimentalstudies, group studies and othertypes of descriptive or comparativestudies.30

♦ Beukelman, Yorkston, & Dowdendescribe an aphasic adult whoused a variety of communicationmethods at home and at work.The subject had severe verbalapraxia and a moderate-severeaphasia. He used an AAC devicewith synthesized speech to

communicate a restricted numberof messages. The device enabledhim to return to work.25

♦ Garrett, Beukelman and Lowreported on an individual withBroca’s aphasia (i.e., limitedexpressive language skills andgood receptive skills) who used amulticomponent AAC system invarious community environ-ments. The AAC device containedindividualized messages thatenabled him to obtain veteran’sbenefits and community-basedtransportation. Also, when heused the AAC device duringcontrolled clinical interactions, hiscommunication breakdownsdecreased from 50% to 17%. Thenumber of his successful commu-nication turns also increased withthe device, compared to when herelied solely on speech andgestures.31

♦ In 1989, Steele and colleaguestrained a person with globalaphasia to express syntacticalforms using an AAC device.Later, they compared an aphasicperson’s ability to comprehendinstructions given in threedifferent language modalities.The synthesized speech devicewas found to be a superior inputmodality for this type of taskwith this type of patient.32

♦ Beck and Fritz tried to determinewhether people with aphasia couldlearn iconic encoding. Theaphasia group had five peoplewith anterior aphasia and fivewith posterior aphasia. Thesecond group consisted of non-brain-damaged controls (n=10).Some people with aphasia didlearn iconic encoding underspecific conditions. The type ofaphasia, level of abstraction andlength of icon sequence influ-enced learning.33

♦ Stuart reported a case in which aman with severe expressiveaphasia resumed several lifeactivities with the assistance of adigitized speech AAC device.34

♦ Hopper and Holland described aman who learned to use an AACdevice to get emergency help overthe phone.35

♦ Cress and King documented theuse of AAC strategies and deviceswith two individuals with primaryprogressive aphasia. They de-scribed an ability to communicateby phone using an AAC deviceand the use of symbols to “chat,”express preferences and opinionsand identify storytelling topics.36

♦ Researchers in the United King-dom evaluated an AAC systemcalled TalksBac with fournonfluent adult aphasics. Thisword-based software exploits theability of some nonfluent aphasicsto recognize familiar words andshort sentences. After a 9-monthtraining period, two subjects hadimproved in their conversationalabilities.

37

♦ Fox, Sohlberg & Fried-Okeninvestigated the outcomes of AACintervention for adults withseverely limited spoken languageabilities and moderate-to-mildauditory comprehension impair-ments. Results showed that theiruse of conversational communica-tion aids improved over time in aclinical environment.38

♦ Finally, Kagan reported thatindividuals with aphasia cancommunicate effectively withmedical professionals who aretrained to use AAC strategies inways that support conversationswith their patients.39 Studies alsodocument the importance of

5

Table II. An estimate of AACdevice requests over time

For Consumers, Continued from page 5

appropriate partner training andsupport for successful AAC use inaphasia.40,41

Who will benefit?

HCFA asked the AAC workinggroup to estimate the number ofMedicare beneficiaries who mightbenefit from AAC devices. TheFormal Request states that thecurrent demand for Medicarereimbursement of AAC devices isseverely constrained by two factors:(1) Medicare’s existing AAC guid-ance and (2) the limited number ofSLPs who have expertise in AAC.Thus, any future change in demandfor reimbursement will dependprimarily on the withdrawal and/orreplacement of the current AACdevice policy and will require aperiod of education and training forSLPs who are unfamiliar with AACtreatment options.

Estimating need. There are over38 million people in the U.S. eligiblefor Medicare. The 1990 Bloomberg

Dissemination andtraining

The AAC-RERC, which is funded bythe National Institute of Disabilityand Rehabilitation Research, hasentered the second year of its fiveyear cycle of funding. Researchpartners at Duke University, PennState University, Temple University,the State University of New York atBuffalo, the University of NorthCarolina and the University ofNebraska are working together on anumber of exciting research anddevelopment projects aimed at

and Johnson study in Australia(selected because of the comprehen-siveness of its data gathering) showsa .12 percent prevalence of severecommunication impairments (SCI)in the general population.42 Hence,the prevalence of Medicare beneficia-ries with SCI in the U.S. is estimatedat 45,600 persons.

Because there is a need for AACeducation and training among theSLPs who serve Medicare beneficia-ries, the demand for AAC deviceswill grow slowly. In addition, noteveryone with a severe communica-tion impairment wants to use anAAC device. Thus, the workinggroup estimated that in the first yearafter Medicare changes its coverage

policy, 100 to 200 beneficiaries willsubmit device claims. Then, ifcoverage for AAC devices is forth-coming, a 50 percent increase in thenumber of AAC device claims eachyear can be expected. Table II showsthat by year five, 505 to 1,013 benefi-ciaries may request AAC devices,making the cumulative five-yearestimate to be no more than 2,638AAC device claims.

Estimating cost. The types ofAAC devices requested will vary andso will the cost. AAC devices costfrom less than $500 to more than$7000, with the majority fallingsomewhere in the middle.

The AAC working group con-cluded that compared to otherMedicare coverage programs, thecost implications are minimal. Thepotential benefits to Medicarebeneficiaries and their families willfar outweigh the costs of the pro-gram.

improving the designcharacteristics and,ultimately, the appropri-ateness, efficiency and

effectiveness of AACdevices and accessories.

An important component of theAAC-RERC’s mission is to providetraining and disseminate informationthat has the potential to improve thelives of people with severe communi-cation impairments. Several membersof the AAC-RERC contributed theirtime and expertise during thepreparation of the Formal Requestfor an AAC Device National Cover-age Decision. Now, through thepublication of this document, theAAC-RERC is supporting efforts todisseminate clinically relevantinformation about the Formal

Request. Our hope is that Medicarebeneficiaries with AAC needs (andthe service providers and manufac-turers who support them) can beready to respond if HCFA replacesthe existing guidance with a profes-sionally and programmatically soundnational coverage standard for AACdevices in the U.S. This could occuras early as March 31, 2000. Look forupdates on the AAC-RERC website[http://www.aac-rerc.com]

The AAC-RERC section is partially funded bythe National Institute on Disability andRehabilitation Research of the Department ofEducation under grant number H133E980026. Theopinions are those of the grantee and do notnecessarily reflect those of the U.S. Dept. ofEducation. Published January, 2000 byAugmentative Communication Inc., 1 Surf Way,#237, Monterey, CA 93940.

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Continued on page 8

The AAC assessment

process

The Formal Request for an AACDevice National Coverage Decisionfocuses on AAC devices. In reality,however, clinical decisions regardingAAC intervention are made in thecontext of a comprehensive speechand language assessment. Speech-language pathologists (SLPs) gatherdata which enable them to make adiagnosis, a prognosis for improve-ment and decisions about appropriatetreatment. When a SLP determinesan AAC assessment is necessary, adevice may be considered to meetfunctional communication goals.

The outcome of an AAC assess-ment is a narrative report thatdescribes the clinical facts relevant tothe speech-language impairment, theneed for and type of AAC treatmentand a detailed treatment plan (whichmay include AAC services, trainingand an AAC device). When a deviceis recommended as part of thetreatment plan, the report specifiesthe functional communication goalsthat will be achieved using the AACdevice. The AAC treatment plan isbased on the clinical facts presentedand the SLP’s professional judgment.

To assist SLPs in the assessmentand decision making process thatleads to the selection of an AACdevice, the Medicare working groupdeveloped a clinical decision makingparadigm and identified nine clinicalindicators, as described below.

Clinical decision making

During the course of the AACassessment, six major clinicaldecisions are made regarding theneed for AAC treatment and the type

o f treatment required. SeeTable III.

1. Determining1. Determining1. Determining1. Determining1. Determiningcurrent functionalcurrent functionalcurrent functionalcurrent functionalcurrent functional

communication levels.communication levels.communication levels.communication levels.communication levels.The SLP first determines the

type, severity and anticipated courseof the individual’s communicationimpairment, i.e., dysarthria, apraxiaof speech and/or aphasia.

Assess current communicationneeds. The SLP seeks to identify theindividual’s daily communicationneeds in order to establish functionalcommunication goals. The scope ofan individual’s communication needsmay range from simple expressionsof wants and needs to a caregiver, tothe communication of complexthoughts and ideas to people inmultiple settings. The needs assess-ment will result in an individualizedprofile of communication needs andwill indicate the importance of eachneeds category.5

Assess communication effective-ness. Using the individualizedcommunication needs profile, theSLP considers whether, given theseverity of the individual’s currentlevel of speech and language impair-ment, daily communication needscan be met using natural modes ofcommunication. The assessmentdetermines whether an individual isable to communicate effectively usingnatural speech in everyday conversa-tions and occurrences.

2. Predicting future levels of2. Predicting future levels of2. Predicting future levels of2. Predicting future levels of2. Predicting future levels ofcommunication effectiveness. communication effectiveness. communication effectiveness. communication effectiveness. communication effectiveness. Whencommunication needs are met, notreatment is recommended. Whenthe assessment process shows thatindividuals are able to meet all theirdaily communication needs throughspeech and other natural communi-cation methods, and their condition isnot expected to deteriorate further,then no AAC treatment is recom-mended.

Assess potential for deteriorationin natural communication skills. Ifthe SLP determines that theindividual’s communication effective-ness is likely to deteriorate due to thenatural course of the disease/condition (e.g., speech is becomingunintelligible) and communicationthrough natural modes will becomeimpossible, the SLP may recommendthat AAC treatment begin.

3. Identifying functional commu-3. Identifying functional commu-3. Identifying functional commu-3. Identifying functional commu-3. Identifying functional commu-nication goals and treatment ap-nication goals and treatment ap-nication goals and treatment ap-nication goals and treatment ap-nication goals and treatment ap-proaches. proaches. proaches. proaches. proaches. Identify functional com-munication goals. When recommend-ing AAC treatment, the SLP needs todefine a list of functional communi-cation goals. Medicare says func-tional communication goals “reflectthe final level the patient is expectedto achieve, are realistic, and have apositive effect on the quality of thepatient’s everyday functions.43

Functional goals can result in a“small, but meaningful change thatenables the beneficiary to functionmore independently in a reasonableamount of time.”44 Examples are to:indicate yes/no responses; communi-cate basic physical needs or emotionalstatus; communicate self-care andmedical needs; use a basic spokenvocabulary and short phrases; engagein social communication with familyand friends; engage in communica-tive interactions in the community;utilize conversational language skills;

Table III. Clinical decisionmaking for AAC assessment

7

Clinical News, Continued from page 7

talk on the telephone and respond toemergencies.

Assess potential to improvenatural communication methods.SLPs determine whether functionalcommunication goals can be achievedusing natural communicationmethods (speech, writing or ges-tures). If the assessment suggeststhey can, then treatment to improvenatural speech or language perfor-mance will begin.

When individuals with severedysarthria, apraxia of speech and/oraphasia do not demonstrate thepotential to meet their communica-tion needs using natural speech, theSLP will often recommend AACapproaches to achieve functionalcommunication goals and improvecommunication effectiveness.4. Selecting specific AAC treatment4. Selecting specific AAC treatment4. Selecting specific AAC treatment4. Selecting specific AAC treatment4. Selecting specific AAC treatmentapproaches. approaches. approaches. approaches. approaches. The next steps of theassessment lead the SLP to decideabout the type of AAC treatmentrequired and whether an AAC deviceand accessories are necessary.

Select AAC treatment options.AAC treatments may include threedifferent approaches to augmentingspoken communication: (1) a speechoutput AAC device; (2) nonelectronicaids such as alphabet, word andpicture boards; and (3) unaidedcommunication strategies such asgestures, speech approximations,listener-supported AAC techniquesand sign language. Most individualsuse a combination of these ap-proaches. However, the FormalRequest focuses only on the part ofthe AAC assessment that leads to theselection of a speech output commu-nication device.Determine message formulationcapability. An important first step inselecting an AAC device and otherAAC treatment approaches is todetermine whether an individual has

the potential to generate messagesindependently using languagesymbols, e.g., pictographs, words,letters or other types of symbols. Ifthe SLP determines the person can,then the assessment will determinethe individual’s most efficient andeffective method of doing so using anAAC device. If the assessment resultsindicate that the individual will beunable to use language symbolsindependently, then the SLP mayinvestigate ways in which the indi-vidual can express messages with theassistance of a communicationpartner rather than an AAC device.

5. Selecting an AAC device and5. Selecting an AAC device and5. Selecting an AAC device and5. Selecting an AAC device and5. Selecting an AAC device andaccessories. accessories. accessories. accessories. accessories. For individuals who areable to formulate messages indepen-dently using words, letters or graphicsymbols, the assessment processfocuses on which kind of AAC deviceand accessories to recommend. Theprocess of selecting an AAC devicerequires that the SLP takes intoconsideration the person’s languagecapabilities and needs, representa-tional abilities, message storage andretrieval requirements, rate enhance-ment features, ability to access thedevice efficiently, visual skills, abilityto use a dynamic display, portabilityissues, training needs and so on.

Determine need to generatemessages by use of spelling. As partof the AAC assessment for an AACdevice, the SLP ascertains whether aperson can spell sufficiently well togenerate messages independently. Ifso, a synthesized speech device willbe needed.

Determine if person generateslanguage most efficiently andeffectively with a device that hasextensive storage and rate enhance-ment features. The AAC assessmentprocess also determines whetherindividuals who can generate lan-

guage independently have the need tostore and retrieve a large amount oflanguage to meet their functionalcommunication goals. For example,individuals wishing to preparemessages in advance, as well as thosewho need to provide large amounts ofinformation (e.g., describe changes intheir medical condition, reactions to amedication or quickly ask questionsrelated to a shopping list) requireAAC devices with the capacity tostore previously created messages andto retrieve their stored messagesefficiently and effectively.

Determine ability to use directselection access. It is important todetermine how an individual willaccess an AAC device. The SLP maycollaborate with other allied healthprofessionals to assess whether directselection access is possible. There aretwo direct selection techniques: (1)direct physical contact using a finger,another body part, stylus, hand-heldpointer, head stick or mouth stick and(2) direct selection techniques usingan electronic accessory.

Determine ability to use indirectaccess (switches). When individualshave severe physical impairments orother difficulties that preclude directaccess to AAC devices, the SLPconsiders indirect selection tech-niques to access an AAC device. Thisportion of the AAC assessment isoften conducted in collaboration withother allied health professionals. Itproduces information about scan-ning-based selection techniques,Morse code and the use of switches.

Specific AAC device recommen-dation. After determining that avoice output AAC device will beappropriate for the individual andidentifying the appropriate devicecategory (see the EquipmentEquipmentEquipmentEquipmentEquipment section),the SLP matches the capabilities ofthe individual to the characteristics ofa specific AAC device and accesso-

8

Continued on page 10

Table IV. Nine clinical indicators for AAC device sub-categoriesries. Typically, the matching processyields a short list of AAC devices andaccessories from which the indi-vidual, family and allied healthprofessionals can select.

At this point, the SLP alsodetermines the extent to whichspecific no-tech strategies and low-tech aids will be used to complementthe use of a speech output AACdevice in ways that help the indi-vidual achieve his or her functionalcommunication goals and optimumcommunication independence.

6. Determining procurement,6. Determining procurement,6. Determining procurement,6. Determining procurement,6. Determining procurement,training and follow up. training and follow up. training and follow up. training and follow up. training and follow up. Because theAAC device will be new to thebeneficiary and caregivers, a periodof instruction and practice is re-quired if the individual is to becomecommunicatively effective using thedevice. SLPs sometimes encourage atrial use period prior to recommend-ing the purchase of an AAC device.

After a device is purchased anddelivered and an initial instructionand practice period has been com-pleted, the SLP conducts anothercommunication needs assessment todetermine whether the individual’scurrent communication system,which now includes an AAC device aswell as residual natural communica-tion and typically no-tech and low-tech AAC strategies, allows theperson to communicate more effec-tively and to achieve functionalcommunication goals.

Over time, modifications may berequired to the AAC treatment plan.Some individuals require follow-up toresolve technical difficulties, trainnew support personnel and monitorthe achievement of functionalcommunication goals.

Clinical indicators

Table IV lists the nine clinicalindicators. The working groupdeveloped these indicators/criteria to

guide the AAC device selectionprocess, at least for Medicare cover-age. The three categories of AACdevices are explained in the Equip-Equip-Equip-Equip-Equip-mentmentmentmentment section.

Clinical indicators 1 and 2 leadthe SLP to consider whether AAC isan appropriate approach to treatment.Both the first indicator (Does theindividual have a communicationdisability with a diagnosis of severedysarthria, apraxia of speech and/oraphasia?) and the second indicator(Will natural communication meth-ods be insufficient for the individualto meet the communication needsthat arise in the course of currentand projected daily activities?)require a positive response beforeAAC treatment of any kind isconsidered.

The third clinical indicator (Doesthe individual require a speechoutput communication device tomeet his/her functional communica-tion goals?) considers whether anAAC device is required. A positiveresponse leads to an AAC deviceassessment.

From this point, for Medicarepurposes, the AAC assessmentfocuses on the kind of AAC device torecommend. For example, the fourthclinical indicator (Does the indi-vidual possess the linguistic capacity

to formulate language (messages)independently?) requires consider-ation of the kind of language theperson is capable of generatingindependently. Some individuals willrequire a “whole message” AACdevice; others can selectpreprogrammed components ofmessages; and some can constructtheir messages independently usingwords, letters or graphic symbols.

The fifth clinical indicator (Doesthe individual produce messagesmost efficiently and effectivelyusing spelling?) requires that the SLPascertain whether a person can spellsufficiently well to generate messagesindependently. If the answer is “yes,”then the individual will require asynthesized speech device to generatespoken messages using spelling. If“no” is the answer, the individualwill need an AAC device that doesn’trequire spelling to formulate mes-sages.

The sixth clinical indicator (Doesthe individual require an AACdevice that provides extensivelanguage storage capacity andefficient retrieval techniques?)addresses whether the individualwishes to prepare messages inadvance and provide large amountsof information in an efficient man-

9

AAC device categories

Because individuals with severecommunication disabilities present awide range of physical, cognitive,linguistic, sensory and motor deficits,as well as different daily communica-tion needs, a variety of AAC deviceconfigurations exist. As a practicalmatter, no single device can offer thenumber of features required to enableall individuals with AAC deviceneeds to achieve effective andefficient communication.

For the purposes of Medicarefunding, the working group devel-oped a paradigm that created three

technologically andclinically distinctcategories of AACdevices:

♦ Digitized speech AACdevices.

♦ AAC devices with synthesizedspeech output, which require thatmessages be formulated byspelling using physical contactdirect selection techniques.

♦ Synthesized speech AAC deviceswith multiple message generationand multiple access options.

Each category offers features that canbe matched to an individual’s profileof physical, cognitive, linguistic,sensory and motor deficits and to theperson’s communication needs. Theyare described below and depicted in

Table V.The main feature that distin-

guishes AAC devices are the type ofspeech output they offer:

♦ Digitized speech is essentially thenatural speech of an individual otherthan the AAC device user —a spouse,SLP or other person selected by the user— that is recorded, stored and recalled.AAC devices with digitized speech arerecognized in the professional literatureas “closed” systems because theyreproduce only those words or messagesthat have been prestored for their user.Digitized speech devices also are called“whole message” systems because theuser can access an entire phrase,sentence or message by a single switchselection on the AAC device.

♦ × Speech synthesis is a technologythat translates the user’s input intodevice-generated speech using algo-rithms representing linguistic rules,including rules for pronunciation,exceptions, voice inflections, andaccents of the language. Synthesized

Clinical News, Continued from page 9

ner. If so, an AAC device with thecapacity to store previously createdmessages and retrieve the messagesefficiently and effectively is needed.If the answer is “no,” then an AACdevice without extensive storage andretrieval capacity is sufficient.

Another important component ofthe AAC device selection processdetermines the most efficient andeffective method of access to an AACdevice. The initial focus is on directselection. The seventh clinicalindicator (Can the individual effec-tively access the device by physicalcontact direct selection techniquesand use any of the following (afinger, another body part, stylus,hand held pointer, head stick, mouthstick)) and the eighth clinical indica-tor (Can the individual access thedevice by direct selection techniquesusing an electronic accessory?) seek

to determine the most efficient andeffective methods of direct selectionaccess. If the answer to the seventhclinical indicator is “yes,” then anelectronic accessory will not berequired. However, if the answer is“no,” then the SLP, with assistancefrom other health care professionals,considers the eighth clinical indicatorand evaluates a range of electronicaccessories, such as a head mouse,track ball or infrared pointer.

When direct access is not pos-sible, or when it is not the mostefficient and effective method ofaccess, then the ninth indicator isconsidered (Can the individualaccess the AAC device by indirectselection techniques?) The AACassessment determines whichindirect selection technique theindividual can use to access an AACdevice and whether the person canuse switches to do visual or auditoryscanning or Morse code.

Final comment

For Medicare reimbursementpurposes, after the SLP has consid-ered all nine clinical indicators andmade decisions about the subcategoryof AAC devices that is appropriatefor the individual and the need fordevice accessories, if any, the processends. But for the SLP, the individualwho will use the AAC device and thefamily, the assessment processcontinues.

10

Continued on page 12

speech AAC devices are described asoffering “generative speech capability”or as being “open systems” becauseusers can construct original messages astheir communication needs dictate.

Category 1

Digitized speech AAC devices.Digitized speech AAC devices.Digitized speech AAC devices.Digitized speech AAC devices.Digitized speech AAC devices. AACdevices with digitized speech requiremessages to be prestored. Theamount of language (words, phrasesor sentences) that can be stored inthe device, and thus selected by theuser, varies greatly. The memorycapacity of AAC devices withdigitized speech output ranges fromdevices that offer a minute or two ofspeech to devices that are configuredto store an hour or more of speech.The Formal Request lists fiveconfigurations: (1) less than 4minutes; (2) 4 to 8 minutes; (3) 9 - 16minutes; (4) 17-32 minutes and (5)more than 32 minutes of recordingtime.

Typically, individuals with cogni-tive or language impairments whoare unable to generate messagesthrough spelling and/or word-by-

word development of their messages(such as people with severe aphasiadue to cortical stroke) find thatdigitized AAC devices meet theirneeds and enable them to achievetheir functional communicationgoals. Thus, if the AAC assessmentprocess determines that the re-sponses to clinical indicators #1, 2and 3 are “yes” and #4, 5 and 6 are“no,” the SLP considers a digitizedspeech AAC device. Because thiscategory of AAC devices offers bothdirect and indirect selection tech-niques, the responses to clinicalindicators #7, 8 and 9 may be either“yes” or “no.” Examples are includedon page 16.

Category #2.

AAC devices with synthesizedAAC devices with synthesizedAAC devices with synthesizedAAC devices with synthesizedAAC devices with synthesizedspeech output which require thatspeech output which require thatspeech output which require thatspeech output which require thatspeech output which require thatmessages be formulated by spelling,messages be formulated by spelling,messages be formulated by spelling,messages be formulated by spelling,messages be formulated by spelling,using physical contact direct selec-using physical contact direct selec-using physical contact direct selec-using physical contact direct selec-using physical contact direct selec-tion techniques.tion techniques.tion techniques.tion techniques.tion techniques. The synthesizedspeech AAC devices in this categoryhave a keyboard for message formu-lation. These devices require that

individuals construct messages onlyby spelling. They also require the useof physical contact direct selectiontechniques, such as use of a finger,hand-held stylus, head stick or mouthstick. Devices in this category do nothave extensive language storage orrate enhancement features that cansupport a user’s ability to construct,store and retrieve lengthy messages.Individuals with ALS or cerebralpalsy who do not have very extensivecommunication needs and who havelost the ability to speak but are goodspellers and retain good fine motordexterity often select AAC devices inthis category to meet their functionalcommunication goals. Clinicalindicators for this category includepositive responses to #1, 2, 3, 4, 5 and7, and negative responses to indica-tors #6, 8 and 9.

AAC devices in this category areappropriate for individuals who havecommunication needs that do notrequire production of lengthy mes-sages, who can spell sufficiently wellto generate their messages and whowill be able to make direct physicalcontact with the keyboard. Examplesof devices in this category are listedon page 16.

Category 3

Synthesized speech AAC devicesSynthesized speech AAC devicesSynthesized speech AAC devicesSynthesized speech AAC devicesSynthesized speech AAC deviceswith multiple message generationwith multiple message generationwith multiple message generationwith multiple message generationwith multiple message generationand multiple access options. and multiple access options. and multiple access options. and multiple access options. and multiple access options. Synthe-sized speech AAC devices in thiscategory permit multiple methods ofmessage formulation and rate en-hancement. They allow users to takeadvantage of text words and/orpictographic symbols to formulatemessages or parts of messages and tospell others. These AAC devices alsoaid individuals who are not literatebut who have the cognitive andlinguistic abilities to generate mes-sages independently. Devices in this

11

Table V. Clinical indicators for selecting AAC devicesfrom three device categories.

Equipment, Continued from page 11

category permit individuals to store alarge number of messages, as well asto create messages in real-time, storelengthy messages and retrieve themefficiently. It is important to note thatAAC software (which is included asan AAC accessory in the FormalRequest) falls within this category.

This category of AAC devicesenables individuals with a very widerange of physical limitations to useAAC devices by offering multipleaccess methods. Individuals canaccess the devices by physical contactdirect selection. However, if that isnot an effective or efficient means ofaccess, e.g., due to quadriplegia orlocked-in-syndrome, individuals canuse an electronic accessory, such as ahead mouse, optical head pointer,light pointer, infrared pointer, eye-gaze or joystick. If none of theseaccessories are appropriate, thesedevices will support access byindirect selection methods, such asswitch-based scanning techniquesand Morse code.

For individuals who need asynthesized speech device withextensive language storage capacityand rate enhancement features, or forsomeone who needs to access adevice by means of direct selectionusing an electronic accessory or anindirect selection technique, a devicefrom the third subcategory will berequired. Clinical indicators for thiscategory require positive responses to#1, 2, 3, 4 and 6. Indicators for #5, 7,8 and 9 may be either “yes” or “no.”See page 16 for some examples.

AAC Accessories

AAC device accessories supporteffective and efficient access todevices and provide proper position-ing of an AAC device, safety duringtransport and an adequate power

supply to meet an individual’scommunication needs throughoutthe day. A SLP will recommendAAC device accessories when theyare necessary.

AAC accessories also includespecific AAC software for individu-als who already have access to acomputer and other necessaryaccessories and only require com-munication software to meet theirfunctional communication needs.

AAC Software: Some manufac-turers of AAC technology offer AACsoftware that is sold separately or inconjunction with a multipurposehardware platform. See page 16 forexamples. This means that whenAAC software is loaded and runningon the computer, the computer“becomes” an AAC device. Theprimary clinical indicator forrecommending AAC software alone(rather than packaged with a hard-ware base) is when the beneficiaryalready has the hardware that suitshis/her needs (e.g., a notebookcomputer, speech synthesizer) andonly requires the AAC software.Clinical indicators for AAC softwareare the same as those for the devicecategory #3.

Alternative access accessories.Decisions about alternative accessrelate to the physical capabilities ofthe user, such as motor skills andvisual abilities, as well as the devicecategory the user needs for commu-nication. When considering alternateaccess accessories, the goal is tomatch the user’s physical abilitiesand limitations with the accessorymost likely to allow the individual toachieve effective and efficientcommunication with the AACdevice. Three types of alternativeaccess accessories exist:

1. Nonelectronic aids that support1. Nonelectronic aids that support1. Nonelectronic aids that support1. Nonelectronic aids that support1. Nonelectronic aids that supportdirect selection.direct selection.direct selection.direct selection.direct selection. For individualswho have the hand, arm, or head

control required to use the deviceusing a hand-held stylus, pointer,splint, keyguard or mouth stick.

2. Electronic aids that support direct2. Electronic aids that support direct2. Electronic aids that support direct2. Electronic aids that support direct2. Electronic aids that support directselection.selection.selection.selection.selection. For individuals who canuse a light pointer, infraredpointer, eye-gaze, joystick oroptical head pointer.

3. Electronic aids (switches) that3. Electronic aids (switches) that3. Electronic aids (switches) that3. Electronic aids (switches) that3. Electronic aids (switches) thatfacilitate indirect selection.facilitate indirect selection.facilitate indirect selection.facilitate indirect selection.facilitate indirect selection. Forindividuals who are unable to useeither of the direct selectiontechniques to operate a AACdevice effectively and efficiently,switch-operated indirect selectiontechniques (scanning) are consid-ered.

Mounting systems. Mountingsystems are necessary to place AACdevices, switches and other accessperipherals in a stable positionrelative to the user. Without appropri-ate mounting for a device and/orswitches, individuals with severemotor or visual impairment areunable to use the appropriate AACdevice to communicate.

Carrying cases. Carrying casesare a critical feature in the identifica-tion and recommendation of appro-priate AAC devices. While they oftenare needed for individuals who areambulatory, they may also benecessary for someone in a wheel-chair whose AAC device is notmounted and must be carried. Forexample, a person with traumaticbrain injury may have a very un-steady gait or use a walker or cane toaid ambulation. A carrying case mayaid the person’s balance in walking,provide protection for the AAC deviceas the person moves from place toplace, and facilitate the individual’suse of the device when and wherevera communication need will arise.Because ongoing daily access to theAAC device is necessary, andbecause the technology in AAC

12

devices is sophisticated and difficultto repair or replace, protection of thedevice to ensure its ongoing function-ing is important.

Power. Because individualsobviously cannot be tethered to awall outlet in order to communicate,all electronic AAC devices rely onbatteries to supply power. For thisreason, all AAC devices are designedwith rechargeable batteries to enablethe user to communicate in anysetting. Typically, batteries arerecharged over night when the user issleeping. In some cases, an indi-vidual will require an additionalbattery to communicate throughoutthe day, just as some individualsinstall a second battery into a laptopcomputer, or have a second batteryfor their cellular telephone. For these

individuals, the additional source ofpower is needed to accommodatetheir ongoing, heavy use of thedevice, and ongoing daily activities orphysical limitations that do notpermit them to recharge batteriesduring the course of the day. Heavy,ongoing usage also may create needsfor other power-related accessories,such as a battery charger, auto-adapter, or AC adapter.

Summary

The sequential nature of theassessment process enables the SLPto consider important clinicalindicators that can lead to a recom-mendation for AAC treatment and fora device from one of the threeproposed AAC device categories.Speech-language pathologists

recommend an AAC device when thefirst three clinical indicators are met.From there, decisions are made aboutwhich type of AAC device can mosteffectively and efficiently meet theindividual’s needs, based on re-sponses to the remaining six clin-icalindicators as shown in Table V.

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13

Proposed National

Coverage Decision

To replace the current Medicarenational coverage decision (NCD) forAAC devices, the following has beenproposed.

Equipment (HCPCS codes)

AAC devicesAAC devicesAAC devicesAAC devicesAAC devicesE xxx 1. AAC devices with digitizedspeech output.

E xxx 2. AAC devices with synthesizedspeech output that require messagegeneration by typing and access bydirect selection techniques.

E xxx 3. AAC devices with synthesizedspeech output which permit multiplemethods of message generation andmultiple access methods.

AAC accessoriesAAC accessoriesAAC accessoriesAAC accessoriesAAC accessoriesE xxx 4-1 AAC software*

E xxx 4-2 AAC accessories: accesstechnologies, direct and indirect

E xxx 4-3 AAC accessories: mountingsystems

E xxx 4-4 AAC accessories: carryingcases

E xxx 4-5 AAC accessories: powersupplies

* Note* Note* Note* Note* Note: For accessory code E xxx 4-1 (AACSoftware) to be covered, the beneficiary mustmeet criteria 4 and 6, and have access to acomputer and related computer accessories suchthat communication needs will be met solely byuse of AAC software.

HCPCS modifiers - Digitized devices**HCPCS modifiers - Digitized devices**HCPCS modifiers - Digitized devices**HCPCS modifiers - Digitized devices**HCPCS modifiers - Digitized devices**

ZV less than 4 minutes of recording time.

ZV 4 - 8 minutes of recording time.

ZV 9 - 16 minutes of recording time.

ZV 17 - 32 minutes of recording time.

ZZ more than 32 minutes of recording time.

**Note**Note**Note**Note**Note: Appropriate use of the Z_ modifier is theresponsibility of the supplier billing the DMERC.This modifier identifies the device that fits withinthe HCPCS code Exxxx1.

Benefit category

Durable MedicalEquipment

Definitions

Augmentative & Alternative Communi-cation (AAC) devices are electronicdevices that provide treatment for severedysarthria, apraxia of speech, oraphasia, when, due to those communica-tion impairments, an individual is notable to meet the communication needsthat arise in the course of current andprojected future daily activities. AACdevices are covered as durable medicalequipment when incorporated into aspeech-language pathology treatmentplan, and when it is determined by aspeech-language pathology assessmentthat an individual is unable to meet thecommunication needs arising in thecourse of daily activities using naturalcommunication techniques.

AAC devices include electronic devicesthat are: a) dedicated communicationdevices and b) portable computers thathave been modified to serve as anindividual’s communication device. Theterm AAC accessories means device-related components, software andaccessories that are necessary additionsto an AAC device, based on the natureand severity of the beneficiary’sdisability, to permit its effective andefficient use.

AAC devices will be covered byMedicare as an item of durable medicalequipment when all of the following aremet: a) the AAC device is recommendedby a speech-language pathologist in anarrative report based on a completeassessment; b) it is incorporated into aspeech-language pathology treatmentplan stating the functional communica-tion goals to be achieved with the AACdevice; c) it is prescribed by thebeneficiary’s physician and d) it issupported by a completed certificate ofmedical necessity.***

*** Note Note Note Note Note: The speech-language pathologynarrative report also must establish whether anindividual for whom HCPCS Codes E xxx 1, 2 or3 are recommended will require any AACaccessories.

Coverage and PaymentRules

1. Digitized speech devicesDigitized speech devicesDigitized speech devicesDigitized speech devicesDigitized speech devices (Code E xxx1) are covered if the patient meets: (a)criterion 1, 2, 3, but not

(b) criterion 4, 5 or 6.

2. AAC devices with synthesized speechAAC devices with synthesized speechAAC devices with synthesized speechAAC devices with synthesized speechAAC devices with synthesized speechoutput that require message generationoutput that require message generationoutput that require message generationoutput that require message generationoutput that require message generationby typing and access by direct selectionby typing and access by direct selectionby typing and access by direct selectionby typing and access by direct selectionby typing and access by direct selectiontechniquestechniquestechniquestechniquestechniques (Code E xxx 2) is covered ifthe patient meets: (a) 1, 2, 3 and 4, 5 and7 but not

(b) 6, 8 and 9.

3. AAC devices with synthesized speechAAC devices with synthesized speechAAC devices with synthesized speechAAC devices with synthesized speechAAC devices with synthesized speechoutput which permit multiple methodsoutput which permit multiple methodsoutput which permit multiple methodsoutput which permit multiple methodsoutput which permit multiple methodsof message generation and multipleof message generation and multipleof message generation and multipleof message generation and multipleof message generation and multipleaccess methodsaccess methodsaccess methodsaccess methodsaccess methods (Code E xxx 3) iscovered if the patient meets (a)criterion 1, 2, 3 and

(b) 4 and 6.

Clinical Criteria

1. The individual has a communicationdisability with a diagnosis of severedysarthria, apraxia and/or aphasia.

2. The individual’s communicationneeds that arise in the course of currentand projected daily activities cannot bemet using natural communicationmethods.

3. The individual requires a speechoutput communication device to meethis/her functional communication goals.

4. The individual possesses the linguisticcapacity to formulate language(messages) independently.

5. The individual’s will producemessages most efficiently and effectivelyusing spelling.

6. The individual will require an AACdevice with extensive language storagecapacity and rate enhancement features.

7. The individual will access the AACdevice and produce messages mostefficiently and effectively by means of aphysical contact direct selectiontechnique, such as with a finger, otherbody part, stylus, hand held pointer,head stick or mouth stick.

8. The individual will access the AACdevice most efficiently and effectively bymeans of an electronic accessory thatpermits direct selection.

9. The individual will access the AACdevice most effectively and efficiently bymeans of a indirect selection technique(e.g., scanning, Morse Code).

14

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Continued on page 16

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devices. Augmentative Communication News.11:4 & 5, p. 13-15.

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3 Lewis Golinker with David Beukelman, SarahBlackstone, Catherine Brown-Herman, KevinCaves, Frank DeRuyter, Lynn Fox, Carol Frattalli,Kathryn Garrett, Audrey Holland, Julia King,Pamela Mathy, Patricia Ourand, Maggie Sauer,Howard Shane and Kathryn Yorkston.

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10 These articles were compiled at the University ofNebraska under the direction of Dr. DavidBeukelman.

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13 Golinker, L. (1990s). In letters and legal briefs.

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17 Glennen, S. L., & Calculator, S. N. (1985).Training functional communication board use: Apragmatic approach. Augmentative & Alterna-tive Communication (AAC), 1:134-142.

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19 Lafontaine, L. M., & DeRuyter, F. (1987). Thenonspeaking cerebral palsied: A clinical anddemographic database report. AAC,3:153-162.

20 Dongilli, P., Hakel, M., & Beukelman, D. (1992).Recovery of functional speech followingtraumatic brain injury. Journal of Head TraumaRehabilitation, 7: 91-101.

21 DeRuyter, F., & Lafontaine, L. M. (1987). Thenonspeaking brain injured: A clinical anddemographic database report. AAC.3:18-25.

22 Ladtkow, M. C., & Culp, D. (1992). Augmenta-tive communication with the traumatic brain-injured population. In K. M. Yorkston (Ed.),Augmentative communication in the medicalsetting (pp. 139-244). Tucson: CommunicationSkill Builders.

23 Radioux, P., Forance, C. & McCauslin, L. (1980).Use of a Handivoice in the treatment of aseverely apractic, non-verbal patient. In R.Brookshire (Ed.). Clinical AphasiologyConference Proceedings (pp. 294-301).Minneapolis: BRK Publishers.

24 Yorkston, K. & Waugh, P. (1989). Use ofaugmentative communication devices withapractic individuals. In P.S. Storer (Ed.). Apraxiaof Speech (pp 2678-283). London: Taylor andFrancis.

25 Beukelman, D. R., Yorkston, K. M., & Dowden,P. A. (1985). Communication Augmentation: Acasebook of clinical management. Boston:College Hill.

26 Rogers, M. & Alarcon, N. (1997). Assessmentand management of primary progressive aphasia:A longitudinal case study over a five year period.Paper presented at the Clinical AphasiologyConference, Flathead Lake, MT.

27 Rogers, M. & Alarcon, N. (1998). Dissolution ofspoken language in primary progressive aphasia.Aphasiology. 12:7-8, 635-650.

28 Holland, A., Fromm, D., DeRuyter, F. & Stein,M. (1996). Treatment efficacy: Aphasia. Journalof Speech and Hearing Research (JSHR). 39:S27-36.

29 Garrett, K. & Beukelman, D. (1998). Adults withsevere aphasia. In Beukelman, D. & Mirenda, P.(Eds.) Augmentative and alternative communi-

cation: Management of Severe CommunicationDisorders in Children and Adults. Baltimore:Paul H. Brookes Publishing Co.

30 Fox, L & Fried-Oken, M. (1996). AACAphasiology: Partnership for future research.AAC. 12:257-271.

31 Garrett, K., Beukelman, D. & Low-Borrow, D.(1989). A comprehensive augmentative system foran adult with Broca’s aphasia. AAC:5:55-61.

32 Steele, R, Weinrich, M., Wertz, R., Kleczewska,M. & Carlson, G. (1989). Computer-based visualcommunication in aphasia. Neuropsychologia.27:409-426.

33 Beck, A. & Fritz, H. Can people who haveaphasia learn iconic codes? AAC. 14(3): 184-196.

34 Stuart, S. (1995). Expanding communicativeparticipation using augmentative and alternativecommunication within a game playing activityfor a man with severe aphasia. ASHA AACSpecial Interest Division Newsletter. 4(1): 9-11.

35 Hopper, T. & Holland, A. (1998). Situation-specific training for adults with aphasia: Anexample. Aphasiology. 12(10): 933-944.

36 Cress, C. & King, J. (1999). AAC strategies forpeople with primary progressive aphasia withoutdementia: Two case studies. AAC. 15:248-260.

37 Waller, A., Dennis, F., Brodie, J., Carins, A.(1998). Evaluating the use of TalksBac, apredictive communication device for nonfluent

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References, Continued from page 15

adults with aphasia. International Journal ofLanguage and Communication Disorders. 33(1):45-70.

38 Fox, L., Sohlberg, M. & Fried-Oken, M. (inpress). Meaningful communication roles foradults. In D.R. Beukelman, K.M. Yorkston & J.Reichle (Eds.). Augmentative Communicationfor Adults with Neurologic Disabilities.Baltimore: Paul H. Brookes.

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60.43 Medicare Intermediary Manual (HCFA Pub. 13)

(“MIM”) 3905.3 (A).44 Medicare Manual (HCFA Pub. 10) (“MHM”)

446(a)(3)(A).

Device Category ExamplesCategory 1: Digitized speech devices Category 1: Digitized speech devices Category 1: Digitized speech devices Category 1: Digitized speech devices Category 1: Digitized speech devices: the

MessageMates (Words+, Inc.); Macaws (Zygo);Hand Held Voice (Mayer Johnson Co.);AlphaTalker (Prentke Romich Co.); SpeakEasy(AbleNet, Inc.); Dynamo (Dynavox Systems,Inc.).

Category 2: Synthesized speech devices Category 2: Synthesized speech devices Category 2: Synthesized speech devices Category 2: Synthesized speech devices Category 2: Synthesized speech devices(message formulation by spelling, access by (message formulation by spelling, access by (message formulation by spelling, access by (message formulation by spelling, access by (message formulation by spelling, access byphysical contact direct selection) physical contact direct selection) physical contact direct selection) physical contact direct selection) physical contact direct selection): LightWriters(e.g., SL25, SL35, SL35C) (Zygo); Link(Assistive Technology Inc.).

Category 3: Category 3: Category 3: Category 3: Category 3: Synthesized speech devices with Synthesized speech devices with Synthesized speech devices with Synthesized speech devices with Synthesized speech devices withmultiple methods of message formulation and multiple methods of message formulation and multiple methods of message formulation and multiple methods of message formulation and multiple methods of message formulation andmultiple methods of device access. multiple methods of device access. multiple methods of device access. multiple methods of device access. multiple methods of device access. Freestyle(Assistive Technology, Inc.; Vanguard (PrentkeRomich Co.); Dynamyte 3100 (DynaVoxSystems, Inc.); Freedom 2000 (Words+, Inc.);Optimist 100 (Zygo); Synergy mAAC 2(Synergy).

AAC Software AAC Software AAC Software AAC Software AAC Software: EZ Keys (Words +, Inc.);Speaking Dynamically (Mayer Johnson).

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