Navigating Speech Therapy Claims: Insights from an Auditor

Speech therapy claims present unique challenges for both providers and payers. In my experience, documentation issues, compliance missteps, and billing inconsistencies frequently raise red flags, leading to audits and claim denials. Understanding these pitfalls is crucial for ensuring compliance and maintaining the integrity of the claims process.

??Common Issues in Speech Therapy Claims

One of the biggest issues I’ve encountered is the lack of awareness surrounding proper documentation and billing practices. Some of the most frequent challenges I see include:

• Incomplete Treatment Plans: Initial evaluations are completed, but the subsequent treatment plans often lack required signatures from parents or guardians when applicable. Additionally, documentation frequently fails to demonstrate family involvement in the planning process.
• Duplicated Documentation: The plan of care is often a direct copy-paste of the treatment plan in the medical record. In some states, these are separate documents with distinct purposes. CMS guidelines specify that "Services must relate directly and specifically to a written treatment plan."
• Lack of Referrals: Many medical records for speech therapy services are missing the necessary referrals, making it difficult to validate the necessity of treatment.
• Unclear Service Narratives: Often, the documentation of services rendered is challenging at best to understand. If I have to decipher what was done, it’s not clear, concise, accurate, or complete.

??Billing Practices That Raise Red Flags

Certain patterns in speech therapy billing immediately catch my attention during audits. These include:

• Excessive Therapy Services: Billing multiple therapy services (e.g., PT, OT, SLP) on the same date of service isn’t inherently problematic, but documentation must clearly justify each service.
• High Frequency of Speech Therapy: When speech therapy is billed at nearly every visit for all clients, it raises concerns and warrants closer scrutiny.
• Provider Outliers: Some providers bill an unusually high number of speech therapy services within a short time frame and geographic area, making them stand out in data analysis and triggering further review.

??Best Practices for SIUs and Payers

For Special Investigation Units (SIUs) and payers, tackling speech therapy claim issues requires a proactive approach. Based on my experience, here’s what works best:

• Know the Regulations: If you don’t understand your state and federal guidelines from the start, you’re setting yourself up for failure.
• Work with Certified Coders: Having a certified coder on staff ensures that claims align with current coding standards and regulations. I have audited several providers who were never informed of code changes, leading to improper billing—unfortunately, ignorance is not a defense.
• Stay Updated on Code Changes: Coding updates occur regularly. If codes change, providers must transition to the new set immediately. I’ve encountered too many cases where providers were still using outdated codes simply because no one told them otherwise.
• Ensure Clear Documentation: If you need to explain what your note means after completing your documentation, then it isn’t clear. Notes should be concise and comprehensive to withstand scrutiny.

Speech therapy claims are complex, and improper documentation or billing can lead to audits, denials, and financial losses. From my perspective as an auditor, providers must take responsibility for understanding guidelines, maintaining clear documentation, and following proper coding practices. SIUs and payers must remain vigilant and proactive in identifying and addressing red flags to uphold the integrity of speech therapy services.

By Robyn Marie Alvarado, CPC, CPMA | Documentation Auditor