Audit Red Flags

Medicaid Toolkit

This is not an exhaustive list or a billing checklist. Please refer to ASHA Billing and Reimbursement resources for additional information or contact ASHA at reimbursement@ASHA.org.

Common Red Flags

• ICD-10 codes do not support the CPT code billed. For example:
  • ICD-10 of F80.2 (Mixed receptive-expressive language delay) with CPT code of 92526 (feeding/swallowing treatment).
• Documentation uses vague terminology. For example:
  • “Mild” impairment, “some” progress, “very little impact.”
• Clinicians use incorrect or missing modifiers. For example:
  • A state Medicaid program may require a “59” modifier to be used when two separate and distinct services are billed on the same day.
  • Some states require a modifier of “95” or “GT” for services provided via teletherapy.
  • Using a “52” modifier for time-based codes when minimum time has not been met.
  • Not putting an LT or RT modifier on a hearing aid code, if required by payer. 
• Clinicians use an incorrect combination of CPT codes on the same day. For example:
  • Billing 92522 (evaluation of speech sound production) and 92523 (speech-language evaluation) on the same date of service. These are viewed as repeated or duplicated services because 92523 includes evaluation of speech sound production. 
  • Billing 92636 (hearing aid post fitting follow-up services) and 92628 (evaluation for hearing aid candidacy) on the same date of service.
• Documentation is missing formal or criterion-referenced data. For example:
  • There is no standardized assessment data or justification of why a standardized assessment was inappropriate. 
• There is no medical necessity statement.
  • A strong medical necessity statement should explain why the speech-language pathology service is required to diagnose, treat, or improve a functional communication or swallowing disorder, rather than simply stating that therapy is beneficial. It should connect the individual's impairment to functional limitations and justify why skilled intervention by a speech-language pathologist is necessary.
  • Medical necessity in audiology should include documenting chief complaint, rationale for extended or reduced testing, and not using “upgrade” when describing the need for a new hearing device.
• There are “cloned” copy/paste templates or identical statements across patients or consecutive dates of service within documentation.
  • Repetitive/identical statements are very easy to identify and increase the risk of more scrutiny from the reviewer.
• Clinicians note repetitive progress data across sessions (i.e. 50% for three consecutive sessions) and/or document a consistent lack of progress (50% for entire 12-week short term goal without modification of goal, level of cueing, or reason for lack of progress). 
  • Repetitive/redundant statements do not represent the individualized responses from your client.
• The clinician does not include skilled descriptive intervention statements and consistently documents a lack of participation across sessions. For example:
  • “Child played with dolls during the session and did not engage in activities.” 
  • "Patient fatigued and did not participate well.”
• The clinician doesn’t include signatures and/or professional credentials.
  • Some policies specify if a “wet” signature is required or if an electronic signature is allowed. The signature must meet state and policy-specific requirements.
• Additional administrative data—including but not limited to plan of care dates, dates of service, referral dates, etc.—are missing from important documentation. For example:
  • An auditor is unable to determine when specific services were ordered, when those services took place, if those services took place within the specified plan of care timeframe, or when a plan of care was signed and implemented.

Be mindful that when you sign your name to a document, you are accepting professional responsibility for its content. Your signature is connected to your license, and you may be held accountable for the information it contains. Before signing, ensure that you agree with the documentation, that it is accurate and complete, and that it aligns with the ASHA Code of Ethics.

Considerations for Audiologists Billing Medicaid

Items to pay close attention to are frequency of benefit, limitations to use of benefits such as age or degree of hearing loss, and documentation requirements. 

Common red flags for audiology audits include deviation from best practice standards, lack of medical necessity, inappropriate use of CPT or HCPCS codes, and insufficient documentation.

Questions? Contact reimbursement@asha.org.