Addressing the Limited Access to an Autism Evaluation: What SLPs Can Do

Speech-language pathologists are often some of the first professionals families call with concerns about autism. Chances are, they have been trying to schedule an autism evaluation for quite some time because increasingly, this is what we hear:

“We’ve been on a waitlist for over a year to see a developmental pediatrician.”

Limited access to autism evaluations is a problem affecting families across the United States. As SLPs, we sit at the intersection of early identification, school eligibility, medical referrals, and insurance access. That means we are uniquely positioned to help.

Our group at Bilinguistics has teamed up with People’s Community Clinic to help families in the Austin area get autism evaluations quicker. It hasn’t been an easy process but we are working our way through the hoops to try to make it happen. In this post, I’ll share the issues, the roadblocks we’ve encountered, and the approach we are shooting for. I’ll touch on:

• Why families are waiting so long for autism evaluations
• How insurance coverage is impacted by an autism diagnosis
• How multidisciplinary teams can help
• Common CPT billing considerations (and challenges)
• How SLPs can use the M-CHAT-R appropriately within their scope to speed up the process of getting to an autism evaluation

Why Are Families Waiting So Long for Autism Evaluations?

Across the U.S., families routinely wait 9 months to well over a year to see a developmental pediatrician. A Rutgers study by Jennifer Forbes Mullenhard found that there are only about 1,000 developmental pediatricians in the United States. This shortage has resulted in delayed diagnoses and delayed early intervention for many children.

In addition to the limited number of fellowship-trained providers, there are many other reasons families have to wait so long for an autism evaluation. They include:

• Increased autism prevalence
• High referral rates from pediatricians and schools
• Insurance requirements that mandate specific provider types
• Geographic disparities (urban concentration, rural shortages)

As a result, children wait during critical developmental windows when early intervention is most impactful. Without a diagnosis, families are often unable to obtain early intervention services for their children.

What is a Developmental Pediatrician?

Let me back up and provide some detail about developmental pediatricians. They are a subspecialty different than a family's general pediatrician. It's an important distinction because families doing the ubiquitous "autism evaluation near me" search can end up contacting the wrong people. This is made worse because many HMO insurance programs require a doctor's name to make a referral. So if the referral is made to the wrong professional it is back to the primary doctor to pay another copay in order to get a proper referral.

A developmental pediatrician is a medical doctor who completes medical school, pediatric residency, and fellowship training in developmental and behavioral pediatrics. They specialize in conditions such as autism spectrum disorder (ASD), cerebral palsy, attention deficit hyperactivity disorder (ADHD), intellectual and developmental disabilities, learning differences, and behavioral and social-emotional disorders. The extensive training of developmental pediatricians contributes to the shortage. In addition to 4 years of medical school and a 3-year pediatrics residency, an additional 3-year fellowship is required. Their training positions them to conduct autism evaluations for children to receive a correct medical diagnosis and also to rule out underlying medical contributors.

The Insurance Barrier: Why Diagnosis Changes Everything

Many insurance companies require a formal autism diagnosis before covering services such as ABA, extended speech-language therapy, occupational therapy, social skills groups, and behavioral health services.

Without a documented diagnosis, families often encounter denied claims, limited therapy caps, and high out-of-pocket expenses. It is important to distinguish between educational eligibility under IDEA and medical insurance authorization, which often requires a formal diagnosis. Insurance companies require a medical diagnosis of autism. Even if a child has been diagnosed with autism in the school setting, the medical diagnosis is still required before insurance will cover autism-related services.

Multidisciplinary Teams: A Practical Alternative

When developmental pediatricians are unavailable, multidisciplinary evaluation teams can conduct high-quality autism assessments. Teams may include: 

• Pediatricians
• Clinical psychologists
• Neuropsychologists
• Speech-language pathologists
• Occupational therapists
• Licensed counselors
• Psychiatrists
• BCBAs
• Social workers
• School psychologists.

This model provides comprehensive evaluation across communication, behavior, cognition, adaptive functioning, and sensory processing. Bowman and colleagues (2021) note that 2 to 3 providers are required to collaborate in making a diagnosis. Some insurances, such as Medicaid, often require at least 3 providers in collaborative diagnostic decision making.

Billing for Autism Evaluations: CPT Codes and Common Pitfalls

CPT billing regulations vary by state, payer, and provider type. Always verify with your state Medicaid program and private insurers. And having said that, the “verifying” part is often incredibly challenging. As a part of setting up our multidisciplinary team, we’ve been on the phone with all of the insurance companies we contract with and it is hard to get the information you need.

We started by telling them what our goal is—to set up a multidisciplinary autism evaluation team to alleviate the wait times that families are experiencing. 

“Great,” they said. “What questions do you have?”

“We’re interested in what codes we can bill.”

“We can’t tell you that. If you tell me a code, I’ll tell you whether a speech-language pathologist is permitted to bill for it. But if I say yes, that doesn’t mean you WILL get paid for it.”

That’s basically the conversation we had over and over. Here are their yes/no answers.

Autism Evaluation CPT Codes and if an SLP can bill for it:

• 96110 – Developmental screening - Yes
• 96112 – Developmental testing (first hour) - Yes
• 96113 – Additional 30 minutes - Yes
• 96130–96131 – Psychological testing - No
• 96136–96137 – Test administration - Yes
• 96116 – Neurobehavioral status exam - No
• 99366 Feedback session with family – No
• 99367 Multidisciplinary team discussion regarding diagnosis without family present – Yes
• 99368 – Team conferences – Not a benefit of Medicaid

We also wanted to know if two or more parties can bill the same code for the same family, given that it is a multidisciplinary team.

Again, no definitive answers. It’s all dependent on factors such as provider restrictions, authorization requirements, bundling, scope-of-practice limitations, and documentation requirements. It makes planning a clinic like this really challenging!

We’ve decided to try out these different pieces one step at a time before scheduling larger groups of children. Our first step is incorporating the M-CHAT-R on the day of the speech evaluation if there are parent concerns about autism or social pragmatic skills.

The Role of SLPs and the M-CHAT-R

The Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R) is a parent-report screening tool for children aged 16–30 months. It assesses early social communication behaviors such as eye contact, response to name, pointing, pretend play, and peer interaction.

The M-CHAT-R provides risk levels, caregiver insight, and justification for referral. It does not diagnose autism but does provide risk levels that guide the next steps for referrals.

In terms of billing, SLPs may bill 96110 for developmental screening in medical settings, depending on state and payer rules. 

Practical Steps for SLPs Using the M-CHAT-R

1. Use standardized social communication screening tools.
2. Document observable behaviors.
3. Build referral networks.
4. Educate families about diagnosis vs eligibility.
5. Verify CPT rules within your state.

Share how you are managing the shortage of autism evaluations in your area.

Limited access to autism evaluations is a systemic issue and many of us are tackling it in different ways. Multidisciplinary models and early identification by SLPs can help families access services sooner and improve outcomes—we just have to figure out all of the hurdles. We’ll keep you posted as we progress through this process. In the meantime, we’d love to hear how you are tackling the issue. Share your comments below.