How I Choose the Right Codes When Partnering with Speech Therapists
Oct 30, 2025
Mental health clients face a hidden challenge that most practitioners miss. Research reveals that 80% of people seeking mental health support have unidentified speech, language, or communication difficulties [10]. These overlooked barriers create frustration, isolation, and misunderstanding that can derail even the most well-intentioned therapy.
The connection between communication struggles and mental health runs deeper than many realize. Studies consistently show strong links between speech impairments and conditions like depression and anxiety [10]. Clients with speech and language disorders experience heightened anxiety, embarrassment, and social withdrawal [11]. Australian data shows 17.5% of adults report mental or behavioral conditions, with anxiety disorders leading at 11.2%. These numbers make collaboration between mental health professionals and speech therapists essential, not optional.
Communication breakdowns damage the therapeutic relationship between clinician and client [13]. Speech therapy exercises strengthen cognitive functions—memory, problem-solving, and concentration—that support mental well-being [11]. My practice has taught me systematic methods for recognizing when speech therapist expertise becomes necessary and how to handle the coding and billing complexities that follow.
This guide shares practical experience building effective partnerships with Speech-Language Pathologists (SLPs). You'll learn to recognize referral moments, understand relevant CPT codes, and document medical necessity properly. The strategies here create ethical partnerships that address your clients' interconnected communication and mental health needs.
These collaborations work. They unlock progress in cases where traditional approaches fall short.
When Therapy Hits a Wall
Clinical practice teaches hard lessons about treatment plateaus. Progress stalls without warning. Clients who seemed engaged suddenly withdraw. What appears to be resistance often masks deeper communication challenges that practitioners miss.
One in five adults experience mental health conditions. Yet most clinicians overlook how communication disorders create treatment barriers. These hidden obstacles prevent breakthrough moments and leave both therapist and client frustrated.
Recognizing Language-Based Resistance in Sessions
True psychological resistance differs dramatically from communication-based struggles. Psychological resistance stems from ambivalence about change. Communication-based resistance emerges when clients cannot express themselves effectively.
The distinction matters. When clients oppose therapy direction rather than express ambivalence, it accounts for 30-32% of variance in homework compliance and 32% of variance in post-treatment outcomes [14].
Key indicators separate language-based resistance from psychological resistance:
Inconsistent engagement: Participation varies dramatically between verbal and non-verbal activities
Frustration without defiance: Disproportionate frustration during routine therapeutic tasks
Mismatched comprehension: Verbal agreement followed by contradictory actions
Selective participation: Enthusiasm for structured activities, avoidance of open discussions
Communication assessment requires accurate symptom descriptions. Language barriers prevent proper mental health recognition and interfere with treatment discussions [2]. This creates a destructive cycle. Clients struggle to communicate, appear uncooperative, then receive inappropriate interventions that worsen engagement.
Ambivalent and oppositional client language correlate positively [14], but they demand different therapeutic responses. Apparent resistance now prompts me to consider pragmatic communication difficulties before assuming treatment opposition.
Why Communication Breakdowns Mimic Psychological Symptoms
Communication disorders and psychological symptoms overlap in dangerous ways. Clients with pragmatic language impairment score two to three times higher on difficulty measures, with risk ratio of 11.3 for boys and 12.3 for girls [14]. Structural language skills explain roughly 15% of problem behaviors. Pragmatic competence emerges as the strongest predictor, explaining over 61% of total difficulties [14].
Social communication issues extend beyond developmental disorders. Two-thirds of children with conduct disorder show clinical-range social communication problems—rates comparable to autism spectrum disorder [14]. Apparent conduct problems may actually reflect undiagnosed communication difficulties.
Anxiety's physical symptoms complicate diagnosis further. Racing heart, shaky hands, trembling voice directly interfere with speech production [15]. Clients experiencing communication difficulty exhibit behaviors remarkably similar to anxiety:
Shortened or hurried conversations
Visible physical discomfort
Topic or interaction avoidance
Self-focused rather than object-focused gestures
Hesitation and response uncertainty
This creates diagnostic confusion. Client disengagement gets attributed to psychological resistance when communication breakdowns are the real cause. Anxiety diagnoses may miss underlying communicative frustration.
Resistance provides valuable diagnostic information rather than obstacles. Unexpected therapy walls now prompt consideration of speech-language pathologist expertise before assuming psychological resistance. This perspective shift transforms apparent impasses into opportunities for comprehensive care through strategic collaboration.
What CPT 92523 Tells Me About My Client
CPT code 92523 offers valuable insights into complex cases where mental health symptoms connect with communication challenges. This specialized code covers comprehensive evaluation of speech sound production and language comprehension. While I never bill this code, understanding what it represents helps me better serve my clients.
Speech sound production and its emotional impact
Speech sound disorders affect approximately 10% of preschool and school-aged children [5]. The psychological effects reach far beyond pronunciation problems. Research shows children with speech sound errors—even minor ones—face negative peer judgments [5]. These clients often develop:
Heightened anxiety and depression symptoms
Reduced social participation
Lower teacher expectations academically
Relationship initiation and maintenance struggles
The emotional impact lasts into adulthood. A 28-year follow-up study found adults with childhood phonological disorders had less favorable academic outcomes and worked disproportionately in jobs requiring minimal academic skills compared to peers [5]. When I see these patterns in therapy, I recognize potential communication challenges rather than simple resistance.
Language comprehension and therapy effectiveness
The language comprehension component of CPT 92523 evaluates a client's ability to process and understand verbal information. This skill directly affects therapy success. SLPs performing auditory processing evaluations use this code [6], showing its relevance extends beyond articulation alone.
Communication disorders impact therapeutic outcomes significantly. When clients oppose therapy direction rather than expressing ambivalence, it accounts for 30-32% of variance in homework compliance [7]. Therapy engagement difficulties often stem from language processing challenges, not psychological resistance.
The International Classification of Functioning framework identifies several domains affected by speech sound disorders: Learning and applying knowledge, Interpersonal interactions and relationships, Communication, and Major life areas [5]. Understanding language comprehension difficulties helps me distinguish between psychological resistance and communication breakdowns.
Why I never bill 92523—but always understand it
I never bill CPT 92523 as a psychotherapist—this would exceed my scope of practice. This code specifically describes speech-language pathologist services for evaluating speech sound production and language comprehension. Understanding what this code covers provides valuable client insights.
Reviewing an SLP's 92523 evaluation gives me specific knowledge about:
How speech sound issues might appear as social withdrawal
Whether language processing difficulties explain therapy challenges
Connections between communication frustrations and anxiety symptoms
How difficulties affect functioning across life domains
The standardized tests under this code provide objective measures of speech production and language comprehension skills [8]. This information helps me separate psychological resistance from communication barriers, preventing misdiagnosis and improving treatment outcomes.
Understanding 92523 informs my referral decisions. The evaluation covers articulation, phonological processes, apraxia, and dysarthria, plus receptive and expressive language [9]. This comprehensive scope helps me identify which clients might benefit from SLP expertise, even when their presentation appears primarily psychological.
Knowing When to Refer to a Speech Therapist
Clinical observation and systematic assessment reveal when communication challenges undermine therapy progress. My practice has shown that referral decisions represent pivotal moments—they can completely alter a client's treatment path. The key lies in recognizing specific patterns that separate communication disorders from psychological resistance.
Red Flags in Children and Adults
Referral decisions start with careful observation. Communication disorders often masquerade as other issues, leading to misdiagnosis and ineffective treatment approaches.
Children show distinct warning signs:
Persistent avoidance of verbal participation despite engagement in non-verbal activities
Disproportionate frustration during verbal exchanges compared to other therapeutic activities
Selective mutism that appears inconsistent with other behavioral patterns
Social isolation despite apparent desire for connection
Academic struggles that contrast with cognitive capabilities
Adult presentations differ but carry equal significance:
Excessive self-monitoring during conversation
Inconsistent therapy engagement that correlates with language-heavy sessions
Difficulty following multi-step instructions despite adequate attention
Recurring misunderstandings about therapeutic concepts
Family feedback about communication difficulties at home or work
Early identification prevents misdiagnosis. Many clients with undiagnosed communication disorders initially receive anxiety, mood, or personality disorder diagnoses. While these conditions may coexist, they don't fully explain the presentation. Recognizing red flags early allows intervention before communication challenges damage the therapeutic relationship.
Explaining the Referral to Clients and Families
Referral conversations require sensitivity. Many clients feel stigmatized or confused by speech therapy suggestions. Frame discussions around enhancing outcomes rather than fixing problems.
For individual clients: "Our communication doesn't seem to flow as smoothly as it could, which might make our work together more challenging than necessary. Working with a speech-language specialist could give us valuable insights about making our sessions more effective."
For families with younger clients: "Children express themselves through communication. When that expression is hindered—even subtly—it affects their emotional well-being. A speech-language pathologist can help us understand if communication patterns might be contributing to the challenges we're addressing."
Always emphasize collaboration, not handoff. The goal is integrated care that addresses both psychological and communication needs simultaneously.
Components of an SLP Referral Letter
Effective referral letters serve as clinical documents and bridges to collaborative care. Structure yours to include:
Client demographics and relevant medical history
Specific behavioral observations that prompted the referral
Current psychological diagnosis and treatment approaches
Explicit description of how communication challenges affect therapeutic progress
Treatment goals that might benefit from speech-language intervention
Assessment requests when appropriate (pragmatic language, articulation)
Preferred communication method for ongoing collaboration
Include informed consent documentation and clarify information sharing expectations. Specify whether you're seeking consultation, assessment, or ongoing co-treatment—distinctions that affect both therapeutic relationships and billing practices.
Effective referral balances clinical precision with interpersonal sensitivity. This methodical approach creates the foundation for integrated care addressing both psychological and communication needs that often intertwine in complex cases.
Billing for My Role in the Collaboration
Financial sustainability drives successful partnerships with speech-language pathologists. Proper billing practices protect both your practice and collaborative relationships. Clear understanding of scope boundaries prevents ethical violations while ensuring appropriate reimbursement.
Using CPT 90785 for Interactive Complexity
CPT code 90785 addresses communication barriers that complicate therapeutic interactions. This add-on code applies when specific factors create diagnostic or treatment obstacles.
I use this code for sessions involving maladaptive communication patterns that complicate care delivery, caregiver emotions or behaviors that interfere with treatment implementation, disclosure of sentinel events requiring mandated reporting, and communication difficulties requiring special therapeutic techniques.
Documentation must clearly identify the complexity factors. When working with a client who has anxiety and pragmatic language difficulties, I document how communication challenges required additional therapeutic techniques—not simply that interpretation was needed.
Code 90785 never stands alone. It must accompany another psychotherapy service code. CMS guidance explicitly states this code "generally should not be billed solely for the purpose of translation or interpretation services" as this may violate federal statute [10].
Interprofessional Consultation Codes 99446–99449
These codes changed how I collaborate with SLPs without direct patient contact. Psychologists gained explicit eligibility to use these codes for consultation services as of January 2023 [11].
The time-based structure works when I consult on behavioral health aspects or seek specialized input. Code 99446 covers 5-10 minutes of consultative discussion. Code 99447 handles 11-20 minutes. Code 99448 addresses 21-30 minutes. Code 99449 covers 31+ minutes of consultation.
Proper reimbursement requires both verbal and written reports to the referring provider, with documented start and end times. Advanced verbal permission must be obtained and documented before consultation occurs [13].
These consultations expand access to specialized care. They allow me to access SLP expertise without requiring additional face-to-face visits. Remote clients and those with mobility challenges benefit significantly.
Documenting Medical Necessity for Collaboration
Medical necessity forms the foundation of reimbursement. Adult services must be "reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain" [14]. Clients under 21 require services that "correct and ameliorate a mental illness or condition" [14].
My documentation addresses how communication challenges worsen or maintain psychological symptoms. I explain why SLP collaboration remains essential for treatment progress. I outline anticipated benefits of integrated care for each specific client. I provide evidence of significant impairment or potential deterioration without collaborative intervention.
Notes consistently explain why each client "still needs therapy" while detailing how interdisciplinary collaboration prevents deterioration or higher care levels [15]. This documentation protects practice operations during insurance reviews while ensuring clients receive appropriate comprehensive care.
Ethical obligations extend beyond clinical excellence to proper billing practices. Careful use of these codes builds sustainable collaborations that respect professional boundaries while delivering integrated client care.
Building a Seamless Treatment Plan with the SLP
Creating effective partnerships with speech-language pathologists requires more than referrals and billing codes. The real work begins when you merge psychological and speech therapy approaches into unified care that serves both domains.
Aligning emotional and communication goals
Successful collaboration starts with understanding how communication and emotional health connect. Partnership with an SLP involves mutual understanding, shared decision-making, and processes that honor family beliefs and preferences [1]. This integrated approach delivers better care because clients receive what they need when they need it [1].
Communication challenges show up emotionally in predictable patterns:
Communication frustrations often present as anxiety
Articulation difficulties frequently lead to social withdrawal
Comprehension issues may appear as noncompliance
Pragmatic language challenges can mimic oppositional behavior
Goal setting for communicative participation draws heavily on client values and preferences—core to evidence-based practice [1]. Parents or clients themselves know their physical and social communication environment best [1]. This knowledge guides goals that address both emotional impacts and technical communication aspects simultaneously.
How we co-create a shared care roadmap
Effective treatment planning with an SLP requires structured collaboration that respects both disciplines. My process emphasizes collective creativity and shared decision-making:
Initial exchange of assessments - Share psychological findings while requesting specific SLP evaluation insights
Joint goal-setting session - Both providers meet with clients to establish unified objectives
Responsibility delineation - Clear documentation of which provider addresses which treatment aspects
Communication protocol - Predetermined schedule and method for ongoing case discussion
This collaboration often begins with goal negotiation and identification [1]. I might ask clients what they want to accomplish over two months of therapy. The SLP explores deeper communication values and needs.
This process works particularly well with children experiencing both emotional and communication challenges. Combined methods allow clients to engage differently [16], addressing varying linguistic and cognitive demands within therapy.
Examples of integrated treatment outcomes
Collaborative care produces results neither discipline achieves alone.
One adult client with social anxiety made minimal progress until an SLP evaluation revealed pragmatic language deficits. Once we incorporated communication strategies alongside exposure therapy, his social confidence improved dramatically. He gained concrete tools for handling conversations.
A child client diagnosed with oppositional defiant disorder showed remarkable improvement when we discovered and addressed an underlying language processing disorder. Combining behavior management techniques with language comprehension strategies, we reduced frustration-based outbursts by nearly 70%.
Speech therapy combined with psychological interventions creates holistic care that addresses underlying emotional, cognitive, and psychological factors impacting communication [17]. Psychologists working alongside speech therapists identify emotional challenges and create personalized treatment plans considering both domains [17].
Communication between all parties enables innovation, knowledge sharing, and acceptance of integrated approaches [18]. This partnership creates powerful synergy—emotional regulation supports communication progress, while improved communication facilitates emotional healing.
Avoiding Legal and Ethical Pitfalls in Collaboration
Ethical boundaries form the foundation of successful collaboration with speech-language pathologists. My practice has revealed specific areas where clinicians must proceed carefully to maintain professional standards and client trust.
Why billing for 92523 is outside my scope
Psychotherapists cannot bill for CPT 92523. This represents a clear scope violation. Professional guidelines restrict speech-language pathologists to practice within their competence, applying principles related to speech, voice, swallowing, and language [19]. Psychotherapists face similar boundaries. Scope of competence differs from scope of practice [20]—knowing about communication disorders doesn't authorize me to diagnose or treat them.
This boundary protects both clients and practitioners. Billing outside your scope creates liability risks and potential fraud accusations.
Avoiding misdiagnosis of language disorders as resistance
Language differences shouldn't be mislabeled as disorders. This leads to unnecessary intervention, misplaced concern, and potential harm [3]. When clients show apparent resistance, I first consider whether language processing issues might be the real cause. True language disorders appear consistently across all languages a person speaks, unlike dialect or cultural expression differences [3].
The distinction matters. Misdiagnosis derails treatment and wastes resources.
Ethical billing for therapists in collaborative care
Transparent billing practices protect everyone involved. I maintain clarity with clients about fees, billing policies, and insurance coverage [4]. Every interprofessional communication gets documented meticulously—detailed notes on patient interactions and informed consent processes [21]. Unintentional mistakes can be perceived as fraud [4], making meticulous record-keeping essential for protecting both my practice and my clients' interests.
Collaboration requires careful documentation. Each billing decision must be defensible and appropriate to my role in the treatment team.
Conclusion
Collaboration with speech-language pathologists changes how we approach complex client presentations. Clients previously seen as resistant or difficult often make breakthrough progress when communication barriers are properly identified and addressed. Success depends on clear boundaries, proper documentation, and mutual respect between disciplines.
Early recognition of communication difficulties prevents misdiagnosis and treatment delays. The distinction between psychological resistance and communication breakdowns becomes clearer with experience. This awareness shifts our entire approach to therapeutic roadblocks.
CPT code knowledge serves us well, even for codes we never bill. Understanding what 92523 represents provides insights into client experiences and informs referral decisions. Proper use of 90785 for interactive complexity and 99446-99449 for interprofessional consultation ensures fair compensation while maintaining ethical standards.
Documentation quality determines reimbursement success. Notes must establish medical necessity, describe specific communication impacts on psychological symptoms, and justify interdisciplinary intervention. Meticulous record-keeping protects practices and serves client interests.
Client transformations make this work rewarding. Social anxiety decreases when pragmatic language skills develop. Behavioral problems often resolve after addressing underlying language processing issues. These outcomes exceed what either discipline achieves independently.
Communication and emotional health connect deeply. Communication struggles create emotional distress. Emotional challenges affect communication ability. Addressing both domains simultaneously produces powerful results.
Professional boundaries require constant attention. Scope limitations must be respected. Language differences shouldn't be pathologized. Billing practices need transparency. These challenges are manageable compared to the benefits of integrated care.
Speech therapy partnership isn't about adding services—it's about recognizing how communication affects emotional well-being. This collaboration offers more complete care and reveals therapeutic potential previously hidden by communication barriers.
Key Takeaways
Understanding the intersection between communication disorders and mental health challenges is crucial for effective therapeutic outcomes and proper billing practices.
• Recognize communication barriers disguised as resistance - 80% of mental health clients have unidentified speech/language difficulties that can mimic psychological resistance or noncompliance.
• Use CPT 90785 for interactive complexity when communication challenges require special therapeutic techniques, but never bill CPT 92523 as it's outside psychotherapist scope.
• Refer to SLPs when therapy stalls unexpectedly - Look for red flags like disproportionate frustration during verbal tasks, selective participation, or mismatched comprehension.
• Document medical necessity meticulously for all collaborative care, establishing how communication challenges exacerbate psychological symptoms and why integrated treatment is essential.
• Build integrated treatment plans that address both emotional and communication goals simultaneously, as this approach produces outcomes neither discipline could achieve alone.
Successful collaboration with speech-language pathologists requires understanding proper billing codes, maintaining ethical boundaries, and recognizing that communication difficulties often fuel emotional distress while emotional challenges impact communication effectiveness.
FAQs
How do I know when to refer a client to a speech therapist?
Look for signs like persistent avoidance of verbal participation, disproportionate frustration during verbal exchanges, selective mutism, social isolation, or academic struggles that contrast with cognitive abilities. In adults, watch for excessive self-monitoring during conversation, inconsistent therapy engagement, difficulty following multi-step instructions, or recurring misunderstandings about therapeutic concepts.
What CPT code should I use when collaborating with a speech-language pathologist?
For interactive complexity due to communication barriers, use CPT code 90785 as an add-on to your primary psychotherapy code. For interprofessional consultations without direct patient contact, use codes 99446-99449 depending on the duration of the consultation. Never bill CPT 92523, as it's outside a psychotherapist's scope of practice.
How can I align psychological and communication goals in a treatment plan?
Work closely with the speech-language pathologist to create a shared care roadmap. This involves exchanging assessments, conducting joint goal-setting sessions with the client, clearly delineating responsibilities between providers, and establishing a communication protocol for ongoing case discussions. Focus on addressing both the emotional impact of communication difficulties and the technical aspects of speech and language.
What should I include in my documentation when collaborating with a speech therapist?
Your documentation should clearly establish medical necessity by detailing how communication challenges exacerbate or maintain psychological symptoms, explaining why SLP collaboration is essential for treatment progress, outlining the anticipated benefits of integrated care for the specific client, and providing evidence of significant impairment or potential deterioration without collaborative intervention.
How can I avoid ethical pitfalls when working with speech-language pathologists?
Stay within your scope of practice by never billing for speech therapy services (like CPT 92523). Be cautious about misdiagnosing language differences as disorders. Maintain transparent billing practices, document all interprofessional communications meticulously, and ensure you have informed consent for collaborative care. Keep detailed records of all collaborative activities to protect both your practice and your clients' interests.
References
[1] - https://www.transformlife.com.au/speech-therapy/how-speech-therapy-can-support-mental-health/#:~:text=feelings of isolation.-,2.,can significantly impact mental health.
[2] - https://www.shakerplace.org/news/the-importance-of-speech-therapy-for-mental-health/#:~:text=Speech therapy is often associated,enhancing their mental well-being.
[3] - https://pmc.ncbi.nlm.nih.gov/articles/PMC8622772/#:~:text=Research has identified a link,friendly therapeutic environment [11].
[4] - https://www.linkedin.com/pulse/essential-role-speech-pathologist-mental-health-teams-kizzy-searle#:~
[5] - https://pmc.ncbi.nlm.nih.gov/articles/PMC4659770/
[6] - https://pmc.ncbi.nlm.nih.gov/articles/PMC7755080/
[7] - https://pmc.ncbi.nlm.nih.gov/articles/PMC9584641/
[8] - https://www.drjordanharris.com/post/the-impact-of-anxiety-on-communication-breakdowns-and-how-to-address-it
[9] - https://pmc.ncbi.nlm.nih.gov/articles/PMC5708870/
[10] - https://www.asha.org/practice/reimbursement/coding/coding_faqs_slp/?srsltid=AfmBOorwCxUhRWCC7ytkmih4aq2tV12iOzltioSQICuAadpjU5m487Z-
[11] - https://pubs.asha.org/doi/10.1044/2018_PERS-SIG1-2018-0016
[13] - https://www.asha.org/practice/reimbursement/coding/new-cpt-evaluation-codes-for-slps/?srsltid=AfmBOopY7MCYMO1SGpuFIgYTRQLqndu-2ecrWdCfegbDIAsRAwnQAf7J
[14] - https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34616_20/L34616_PSYCH014_BCG.pdf
[15] - https://www.apaservices.org/practice/reimbursement/health-codes/interprofessional-consultation-codes
[16] - https://www.the-rheumatologist.org/article/coding-reimbursement-guidelines-for-interprofessional-consultation-codes/
[17] - https://abpp.org/newsletter-post/integrated-psychology-billing-why-is-it-so-difficult-to-get-reimbursed-for-our-services/
[18] - https://www.marinhhs.org/bhrs-clinical-documentation-guide
[19] - https://therapistsupport.rula.com/hc/en-us/articles/41418371667099-Medical-Necessity-Explained-Key-Elements-for-Effective-Documentation
[20] - https://pmc.ncbi.nlm.nih.gov/articles/PMC9796747/
[21] - https://www.researchgate.net/publication/394266982_The_involvement_of_individuals_with_speech_and_language_impairments_in_research_insights_from_a_co-creation_process
[22] - https://www.torontospeechtherapy.com/blog/2023/the-mind-body-connection-speech-language-pathology-and-psychology/
[23] - https://researchinvolvement.biomedcentral.com/articles/10.1186/s40900-025-00762-8
[24] - https://www.asha.org/siteassets/publications/sp2016-00343.pdf?srsltid=AfmBOoruJWalUzjEE89i1Eo1yyYeQCwqQ9YKK5POm6UC3RWj3A4iMwwF
[25] - https://www.op.nysed.gov/professions/audiology/professional-practice/scope-of-competence
[26] - https://duncanlakespeechtherapy.com/dlst-blog/language-difference-vs-disorder/
[28] - https://sananetwork.com/navigating-legal-and-ethical-considerations-in-integrated-practices/
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Not medical advice. For informational use only.
