Speech Therapy Documentation Essentials: Meeting ASHA Standards in 2026

TLDR: Speech-language pathologists working in multi-disciplinary clinics often struggle with PT-centric EMR systems that lack SLP-specific templates, untimed billing code support, and ASHA-compliant documentation frameworks. This comprehensive guide covers the essential documentation requirements for SLPs, including specialized assessment templates (CELF-5, PLS-5, FEES/MBSS), critical billing differences between untimed SLP codes (92507, 92526) and time-based PT codes, the distinct needs of pediatric language development versus adult stroke/dysphagia cases, and how modern multi-disciplinary EMRs can support dedicated speech therapy workflows while maintaining integration with PT and OT services. Proper documentation not only ensures compliance with ASHA standards but also maximizes reimbursement and protects your practice from audits.

The Speech Therapy Documentation Challenge in Multi-Disciplinary Settings

Speech-language pathologists face a unique challenge in today’s healthcare landscape. While many SLPs practice in multi-disciplinary clinics alongside physical and occupational therapists, the electronic medical record systems they’re forced to use are often built exclusively for PT workflows. The result? Frustrated clinicians spending hours creating workarounds, missing critical documentation elements, and risking compliance issues.

According to industry research, speech therapists find billing and record-keeping the most frustrating parts of their job, with medical bills containing errors 80% of the time. Some states have even fined major health insurers for repeatedly denying valid speech therapy claims. One SLP who switched from a PT-centric system noted: “Before we switched, evaluating clients took much longer because I had to write a lot of narrative text, especially in speech therapy evaluations for children, since there were no good templates available.”

The American Speech-Language-Hearing Association (ASHA) maintains rigorous documentation standards that differ fundamentally from physical therapy requirements. Speech therapy documentation must support complex assessments ranging from pediatric language development to adult dysphagia management, each requiring distinct clinical reasoning, specialized outcome measures, and tailored intervention strategies.

Understanding ASHA Documentation Standards for 2026

ASHA’s documentation guidelines serve as the foundation for compliant speech therapy practice. The ASHA Practice Policy documents provide comprehensive frameworks including Guidelines (current best practice procedures based on available evidence), Preferred Practice Patterns (informational base for quality patient care), and Standards/Quality Indicators.

For 2026, ASHA has updated certification standards to clarify professional development content areas effective January 1, 2026. Additionally, Remote Therapeutic Monitoring (RTM) codes (CPT 98974-98986) have been revised to give clinicians more flexibility in digital tool usage, requiring a minimum of 16 days of data transmission per 30-day period for device codes.

Core Documentation Elements Required by ASHA

Every speech therapy documentation system must capture:

Comprehensive Assessment Data: Detailed results from standardized tests (CELF-5, PLS-5, GFTA-3), clinical observations, case history, and patient/caregiver concerns.
Clinical Reasoning: Clear articulation of why specific interventions are medically necessary, how they address identified deficits, and expected functional outcomes.
Treatment Goals: Functional, measurable objectives that demonstrate skilled services requiring the expertise of a licensed SLP.
Intervention Strategies: Specific techniques, cues, materials, and evidence-based approaches used during treatment sessions.
Progress Documentation: Objective measurements showing response to treatment, goal progression, and clinical decision-making regarding plan of care modifications.
Collaboration Notes: Communication with other providers, teachers, caregivers, and interdisciplinary team members.

ASHA’s Medical Review Guidelines emphasize that documentation must demonstrate the skill of a speech-language pathologist was required—not just that exercises or activities occurred. The documentation should reflect clinical expertise in assessment, treatment planning, and ongoing modification based on patient response.

Speech Therapy Billing Codes: Understanding the Untimed Difference

One of the most significant differences between speech therapy and physical therapy billing lies in the structure of CPT codes. While PT relies heavily on time-based 15-minute increment codes following the 8-minute rule, most SLP codes are untimed service-based codes.

Primary Speech Therapy CPT Codes

CPT Code 92507 - Individual Speech Therapy

CPT 92507 covers treatment of speech, language, voice, communication, and auditory processing disorders in individual settings. This is an untimed code billed once per session regardless of duration.

Documentation Requirements for 92507:

Treatment diagnosis related to speech, language, voice, or communication disorder
Clear goals and treatment plan
Specific interventions provided and clinical rationale
Patient response to treatment
Required modifiers: GN (services under SLP plan of care), KX (services beyond therapy cap are medically necessary), 95/GT (telehealth services)

According to billing experts, while 92507 is untimed, it has an underlying time of approximately 60 minutes based on American Medical Association surveys. However, there are no hard and fast rules regarding time minimums—the decision to bill depends on the clinician’s judgment that the service provided was medically necessary and clinically appropriate.

CPT Code 92526 - Swallowing/Dysphagia Therapy

CPT 92526 addresses treatment of swallowing dysfunction and oral function for feeding. Like 92507, this is an untimed code billed once per session.

Documentation Requirements for 92526:

Existing Plan of Care with dysphagia treatment goals
Specific interventions addressing swallowing safety, efficiency, or oral intake
Objective measurements (e.g., diet level, aspiration symptoms)
Functional progress toward safe oral intake

Important: You can bill 92507 and 92526 together on the same day, but documentation must clearly show separate and complete services addressing distinct diagnoses and treatment goals. For example, 92507 for aphasia treatment and 92526 for dysphagia management in a stroke patient.

Critical Differences: Untimed vs. Timed Codes

The distinction between untimed and timed codes creates significant workflow differences between SLP and PT documentation:

Feature	Untimed SLP Codes (92507, 92526)	Timed PT Codes (97110, 97140)
Billing Units	One unit per session, regardless of time	Multiple units based on 8-minute rule
Time Tracking	Not required in documentation	Precise start/stop times mandatory
Multiple Sessions	Cannot bill same code twice same day	Can bill multiple units per session
Modifier Usage	Primarily GN, KX, 95/GT	59, XE, XS, XP, XU for unbundling
Documentation Focus	Service provided and medical necessity	Time spent plus medical necessity

According to ASHA guidelines, most speech-language pathology CPT codes (92507, 92508, 92521-92524, 92526, 92605-92609) are untimed. PT-centric EMR systems often lack the ability to properly configure untimed billing workflows, forcing SLPs to work around time-based templates that don’t match their service structure.

Evaluation Codes: Timed SLP Services

While treatment codes are untimed, SLP evaluation codes follow a time-based structure:

92521: Speech sound production evaluation (typically 30-60 minutes)
92522: Articulation/phonological evaluation (typically 30-60 minutes)
92523: Language evaluation (typically 60-90 minutes)
92524: Behavioral/qualitative analysis of speech/language (typically 60 minutes)

These evaluation codes are considered untimed in descriptor but have underlying time values. Documentation must justify the time invested and complexity of the assessment without requiring minute-by-minute tracking like timed treatment codes.

Assessment Templates: Pediatric vs. Adult Documentation

Speech therapy encompasses vastly different patient populations requiring distinct documentation frameworks. A pediatric language disorder case looks nothing like an adult dysphagia case, yet many EMR systems force SLPs to use generic templates that fit neither scenario.

Pediatric Speech-Language Assessments

CELF-5 (Clinical Evaluation of Language Fundamentals, 5th Edition)

The CELF-5 is a comprehensive language assessment for children ages 5-21. Proper documentation requires:

Score tables for Receptive Language Composite, Expressive Language Composite, and Total Language Score
Subtest results: Sentence Comprehension, Linguistic Concepts, Word Structure, Word Classes, Following Directions, Formulating Sentences, Recalling Sentences, Understanding Spoken Paragraphs, Sentence Assembly, Semantic Relationships
Standard scores, percentile ranks, and age equivalents
Interpretation linking scores to functional communication deficits
Recommendations for intervention targets based on profile analysis

PLS-5 (Preschool Language Scales, 5th Edition)

The PLS-5 assesses language development in children birth through age 7. Documentation should include:

Auditory Comprehension standard score
Expressive Communication standard score
Total Language Score
Developmental milestone achievement
Parent report and observation integration
Play-based assessment findings

Many SLPs report that EMR templates designed for PT evaluations lack the structure needed for pediatric speech assessments, particularly the score tables, percentile calculations, and developmental milestone tracking that are standard in speech-language evaluations for children.

Adult Neurological and Dysphagia Assessments

FEES (Fiberoptic Endoscopic Evaluation of Swallowing)

FEES documentation requires highly specialized templates capturing:

Pharyngeal and laryngeal anatomy (structural abnormalities, secretion management)
Sensory testing (touch stimulation response)
Trial swallow observations by consistency (thin liquid, nectar, puree, solid)
Penetration-Aspiration Scale ratings (1-8 scale)
Residue location and amount (valleculae, pyriform sinuses)
Compensatory strategy effectiveness (chin tuck, head turn, effortful swallow)
Diet recommendations based on findings

MBSS (Modified Barium Swallow Study)

MBSS documentation parallels FEES but includes:

Oral phase observations (bolus formation, containment, propulsion)
Pharyngeal phase timing (pharyngeal delay, swallow initiation)
Hyolaryngeal excursion measurement
Upper esophageal sphincter opening
Aspiration timing (before, during, or after swallow)

According to ASHA clinical guidance, “experience in adult swallowing disorders does not qualify an individual to provide swallowing assessment and intervention for children.” The documentation templates must reflect this specialization, with pediatric dysphagia assessments requiring distinct considerations around developmental feeding skills, growth, and family feeding dynamics.

Stroke Recovery and Aphasia Documentation

Following stroke, dysphagia, dysarthria, and aphasia are reported in approximately 55%, 42%, and 30% of adults, respectively. Documentation for neurological rehabilitation must include:

Western Aphasia Battery (WAB) scores or other aphasia assessment results
Cognitive-linguistic status (attention, memory, problem-solving)
Functional communication measures (ability to express basic needs, comprehend safety information)
Caregiver communication strategies training documentation
Progress in functional terms (e.g., “Patient will improve word retrieval to request pain medication independently” rather than “Patient will improve naming skills”)

Multi-disciplinary clinics treating stroke patients benefit significantly from integrated EMR systems. The pediatric PT EMR features that support developmental tracking can complement SLP pediatric language documentation, while neurological rehab EMR capabilities for balance and mobility assessments align with vestibular and motor speech disorder documentation needs.

Common SLP CPT Codes Reference Table

CPT Code	Service Description	Type	Typical Documentation Elements
92507	Individual speech therapy	Untimed	Treatment diagnosis, interventions, patient response, progress toward goals
92508	Group speech therapy (2+ patients)	Untimed	Group goals, individual participation, social communication dynamics
92521	Speech sound production evaluation	Untimed	Articulation inventory, phonological process analysis, stimulability
92522	Articulation/phonological evaluation	Untimed	Error patterns, consistency, intelligibility rating
92523	Language evaluation	Untimed	Standardized test results (CELF, PLS, etc.), language sample analysis
92524	Behavioral analysis of speech/language	Untimed	Qualitative observations, pragmatic language assessment
92526	Swallowing/dysphagia treatment	Untimed	Diet level, aspiration precautions, therapeutic techniques, safety
92610	Swallowing evaluation (clinical)	Untimed	Oral mechanism exam, trial swallows, diet recommendations
92611	Motion fluoroscopic evaluation (MBSS)	Untimed	Radiographic findings, Penetration-Aspiration Scale, modified strategies
92612	Flexible endoscopic evaluation (FEES)	Untimed	Endoscopic findings, secretion management, aspiration risk
92526	Dysphagia therapy	Untimed	Therapeutic exercises (Shaker, Mendelsohn), compensatory strategies
97129	Therapeutic cognitive skills (initial)	Timed	Cognitive assessment, baseline attention/memory/executive function
97130	Therapeutic cognitive skills (subsequent)	Timed	Cognitive interventions, progress on cognitive goals

Important Billing Note: Speech-language pathologists may perform services coded as CPT codes 92507, 92508, or 92526, but they do not perform services coded as CPT codes 97110, 97112, 97150, or 97530, which are generally performed by physical or occupational therapists. Additionally, SLPs cannot report CPT code 92507 on the same day as cognitive skills codes 97129 and 97130 due to National Correct Coding Initiative (NCCI) edits.

Multi-Disciplinary EMR Requirements for SLP Success

For speech-language pathologists practicing in integrated PT/OT/SLP clinics, the EMR system must support distinct workflows while maintaining unified patient records. Research shows that effective multi-disciplinary EMR systems provide:

1. Specialty-Specific Templates

EMR systems tailored to PT, OT, and SLP workflows should include templates that promote clarity:

SLP Evaluation Templates: CELF-5, PLS-5, WAB, GFTA-3, PPVT with auto-calculated scores
Dysphagia Templates: FEES/MBSS structured reporting, diet level progression, aspiration precautions
Voice Templates: CAPE-V ratings, acoustic analysis integration, vocal hygiene education
Stuttering Templates: SSI-4 scoring, therapy techniques (prolongation, easy onset), situation hierarchy

2. Automated Modifier Management

Multi-disciplinary clinics must manage different modifiers (GP for PT, GO for OT, GN for SLP) automatically based on the provider logging in. The system should:

Auto-apply the GN modifier for all SLP services
Track therapy cap thresholds separately by discipline
Alert when KX modifier documentation is required (services exceeding $2,480 threshold in 2026)
Support telehealth modifiers (95/GT) for remote services

3. Untimed Billing Workflows

Unlike PT systems built around 15-minute time units, SLP-friendly EMRs must:

Allow single-unit billing for 92507/92526 regardless of session length
Prevent accidental double-billing of the same code on the same day
Support documentation of service provision without minute-by-minute time tracking
Enable billing multiple untimed codes (92507 + 92526) with proper documentation

4. Unified Patient Charts with Discipline-Specific Views

Clinics offering PT, OT, and SLP benefit from unified charts that allow coordinated care:

Shared patient demographics and insurance information
Cross-discipline referrals (PT refers stroke patient to SLP for dysphagia assessment)
Integrated progress notes visible to all treating providers
Separate discipline-specific sections for specialized assessments
Co-treatment documentation when PT and SLP treat simultaneously (cannot double bill time)

5. HIPAA-Compliant Security for Sensitive Data

Pelvic health and speech therapy often involve highly sensitive patient information. Enhanced privacy controls should include:

Role-based access controls limiting which staff can view specific note types
Audit logs tracking who accessed patient records
Secure messaging for interdisciplinary communication
Patient portal access allowing clients to review their own records

Addressing the PT-Centric Software Problem

Many multi-disciplinary clinics default to PT-centric EMR systems because physical therapy represents the largest discipline by volume. However, this creates significant friction for SLPs who must constantly work around limitations:

Common Complaints from SLPs Using PT Systems:

No pediatric language assessment templates: “I spend hours typing narrative reports because there are no CELF-5 or PLS-5 score tables”
Time-based billing forced on untimed codes: “The system makes me enter minutes for 92507 even though it’s a per-session code”
Missing dysphagia-specific fields: “There’s nowhere to document diet level, aspiration precautions, or compensatory strategies”
Body charts designed for MSK: “The body diagram shows shoulders and knees, not oral mechanism or pharyngeal anatomy”
Outcome measures geared to mobility: “I need ASHA NOMS, not Oswestry Disability Index”

One SLP reported that before switching to a multi-discipline-friendly system: “Evaluating clients took much longer because I had to write a lot of narrative text, especially in speech therapy evaluations for children, since there were no good templates available.”

Modern EMR platforms designed for true multi-disciplinary practices (like Proactive Chart, Raintree Systems, Clinicient Insight, and Ensora Health) provide dedicated SLP modules with:

Templates for typical evaluations (swallowing exams, voice exams, language/cognitive communication exams)
ASHA-compliant documentation structures
Integration with PT/OT services in a unified platform
Specialized billing rules for untimed codes
Customizable templates for diverse SLP practice areas

Best Practices for ASHA-Compliant Documentation

Regardless of your EMR system, following these documentation best practices ensures compliance and maximizes reimbursement:

1. Document Skilled Services

ASHA and Medicare both require documentation that highlights skilled services, clinical judgment, and objective data. Instead of generic statements like “Worked on articulation,” document:

“Provided systematic articulation therapy targeting /r/ in structured words using simultaneous tactile cues (tongue depressor placement). Patient achieved 70% accuracy with /r/ in initial position CV words (car, core, cord) with moderate cueing, improved from 40% baseline. Clinical judgment: patient demonstrates stimulability and progressing appropriately toward conversational carryover.”

2. Use the SOAP Format

The SOAP format (Subjective, Objective, Assessment, Plan) is commonly used in healthcare settings:

Subjective: Patient/caregiver report, concerns, perception of progress
Objective: Specific data (accuracy percentages, standardized test scores, diet level changes)
Assessment: Clinical interpretation of progress, barriers, response to treatment
Plan: Next session focus, home program modifications, discharge planning

3. Use Consistent Measurements

For dysphagia documentation, clinicians should use consistent measurements and include objective data:

“Swallowed cup sips of thin liquid sans overt s/sx of aspiration in 70% of trials”
“Required verbal cue for chin tuck on 3 of 10 swallows”
“Patient advanced from puree diet to mechanical soft diet with excellent tolerance”

4. Link Interventions to Functional Goals

Speech-language pathology goals should be written in functional terms. For dysphagia:

✓ “Patient will improve laryngeal elevation during swallowing to protect the airway, enabling safe oral intake of thin liquids”
✗ “Patient will improve laryngeal elevation”

For aphasia:

✓ “Patient will communicate pain location and intensity to nursing staff using gesture + word combinations with 80% accuracy”
✗ “Patient will improve word retrieval”

5. Document Medical Necessity

Every note must answer: Why does this patient need the skill of a licensed SLP? Document:

Complexity requiring clinical decision-making
Safety concerns (aspiration risk, communication breakdown affecting medical care)
Prognostic indicators supporting continued treatment
Family/caregiver education requiring professional expertise

6. Maintain ASHA NOMS Data

ASHA’s National Outcomes Measurement System (NOMS) provides functional communication measures across settings. While not required for reimbursement, NOMS data:

Demonstrates outcomes for quality improvement
Supports advocacy for the profession
Provides benchmarking against national data
Strengthens justification for continued treatment

Internal Linking Opportunities

Strategic cross-linking reinforces content authority and helps users discover related resources:

Link to Pediatric PT EMR with anchor text: “pediatric documentation workflows” or “tracking developmental milestones across disciplines”
Link to Neurological Rehab EMR with anchor text: “stroke recovery documentation” or “neurological rehabilitation across PT and SLP”
Link to Group Therapy Billing with anchor text: “group therapy billing for 92508” or “co-treatment documentation rules”
Link to Medical Billing Software for Small Practices with anchor text: “integrated billing for multi-disciplinary clinics” or “automated clearinghouse integration”
Link to EMR Data Security with anchor text: “HIPAA-compliant documentation” or “secure patient records for sensitive diagnoses”
Link to Efficient PT Documentation with anchor text: “documentation efficiency strategies” or “point-of-care documentation workflows”

Conclusion: The Path to Compliant, Efficient SLP Documentation

Speech-language pathologists deserve EMR systems that support their unique clinical workflows, not generic PT templates that require constant workarounds. As multi-disciplinary practices become increasingly common, the need for truly integrated systems supporting PT, OT, and SLP in a unified platform has never been greater.

ASHA-compliant documentation requires:

Specialized assessment templates (CELF-5, PLS-5, FEES/MBSS) with structured data entry
Support for untimed billing codes (92507, 92526) without forced time tracking
Distinct pediatric language and adult dysphagia documentation frameworks
Automatic modifier management (GN, KX) specific to speech therapy
Functional goal tracking aligned with ASHA standards
Integration with PT/OT services for coordinated care

By choosing an EMR system designed for multi-disciplinary rehabilitation practices, SLPs can focus on what matters most: providing skilled speech-language services that improve patient outcomes. The right technology doesn’t just check compliance boxes—it enhances clinical efficiency, supports evidence-based practice, and enables SLPs to deliver the specialized care their patients deserve.

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