Widespread Probe Results and Review Notification – IA – FI – Outpatient Speech Language Pathology (SLP) Services and Current Procedural Terminology (CPT) Code 97532, Development of Cognitive Skills to Improve Attention, Memory, Problem Solving
As a result of the analysis of errors related to the widespread probe review for topic 5TT33 for claims reviewed between October 26, 2006, through March 31, 2007, Cahaba will be initiating a continuing widespread review for types of bills 13X, 22X, 23X, 74X, 75X, and 85X with revenue code 044X and CPT code 97532. The topic code for this review will be 5TT36 and will select claims across the provider community billing these services that meet the parameters of the edit. Once selected, the claims will be reviewed for medical necessity (e.g. compliance with CMS’s guidelines, contractor Local Coverage Determinations (LCDs), correct billing and coding). Results of the widespread probe review are summarized below.
Error rate: 93.42%
Number of providers: 38
For this edit, 76 claims were reviewed with 71 being either partially or fully denied. The majority of claims, 31, were denied because the medical necessity of the services was not supported in the received medical record. LCD, L1078, was established to provide direction in coverage of this service. As stated in the LCD, “SLP services are covered provided such services are of a level of complexity and sophistication, or the patient’s condition is such that the services can be safely and effectively performed only by a licensed qualified Speech Language Pathologist. Services normally considered to be a routine part of nursing care are not covered.”
For cognitive skills training to be covered, the Plan of Care (POC) should document specific short and long-term goals of treatment and that significant gains are reasonable and expected. The documentation should indicate measurable progress toward goals and that the beneficiary is able to participate if compensatory training is part of the treatment. Documentation must be present to support the ability of the beneficiary to follow, learn and retain instruction. Absence of this documentation will result in a denial of services.
Unskilled procedures include procedures which are repetitive and/or reinforcing of previously learned material which the patient or family is instructed to repeat. In addition, procedures which may be effectively carried out with the patient by any nonprofessional (e.g., family member, restorative nursing aide) after instruction and training is completed are considered unskilled and will be denied.
Thirteen claims received denials because there was insufficient documentation for the services provided. This denial occurs when there is insufficient documentation or even missing documentation to support the medical necessity of the service billed. To be covered, the documentation must indicate the skills of a therapist are required based on the condition, complexity and/or complications of the patient.
The documentation in the medical record must also support the number of units billed. CPT code 97532 is a timed code. When using the timed codes, the documentation must support that the units billed reflect the treatment time that is billed, based on actual time of delivered skilled services. It takes a minimum of eight minutes to bill one unit of these codes.
Twelve claims were denied because the necessary documentation was not received. When compiling medical records to respond to an Additional Development Request (ADR), make sure the POC, daily treatment encounter notes, and interval progress notes are included.
Ten claims were denied because the certification for the SLP services was missing or invalid. Outpatient therapy services must be furnished under a written POC. The plan must be established before treatment is begun and promptly signed by the ordering physician, nonphysician practitioner (NPP), therapist, or speech-language pathologist. Certification requires a dated signature by the physician or NPP on the therapy POC “as soon as possible.” The Centers for Medicare & Medicaid Services (CMS) interprets “as soon as possible” to mean as soon as the POC is obtained or before the end of the first interval (within 30 days). When services continue for greater than one month the physician or NPP should review and certify the POC for each interval of therapy. A date for the physician’s signature is required to determine if the certification is a delayed certification. If the physician does not date his/her signature, a received date, identified as such, may be entered. Fax dates are also acceptable. If there is no date for the physician’s signature, the POC is determined to be invalid. Services are not covered.
Six claims were denied because the ADR information was not received. An ADR is a request for additional information for a claim(s) that has been selected for prepayment review. You are notified of ADRs through the Fiscal Intermediary Standard System (FISS) if you bill electronically. When a claim is selected for medical review, it moves to status/location SB6001. It is very important that you establish a procedure in your office to monitor the ADR status/location on a regular basis.
If you submit hardcopies of claims, you will need to monitor your 201 report on a weekly basis. Any claims selected for medical review will have a “Y” in the “ADS” field on the Summary of Pended claims selection and the 39700 Reason Code next to the selected claim below the beneficiary’s name and patient control number. You should then contact the Customer Service Department at (866) 567-3092 to obtain specific information regarding the beneficiary name and patient control number.
It is your responsibility to check for ADRs. If we do not receive the requested information by the timeline noted on the ADR, the entire claim will be denied with reason code 56900. The ADR message includes a list of the following information being requested
The ADR notice tells you what additional medical record information to submit to the intermediary. Please note that the ADR message is specific to the edit, and should be read in its entirety. This additional information is needed to assist the intermediary in making a coverage decision. If more than one edit reason code appears on the ADR letter on the UB-92 claim page 7, list and respond to only the first edit reason code.
Page last updated: May 2, 2007
