How to Prepare an SLP Denial of Treatment Claim

Question

How do I prepare for an SLP Denial (of a treatment claim)since most facilities request the SLP to either write the "denial letter" or provide quite a bit of support to a senior manager who writes the letter (depending on the company)? Many therapists see

Answer

Appealing a denial for skilled therapy services can be a daunting task rife with stress. However, most Fiscal Intermediaries (FIs) or Medicare Administrative Contractors (MACs) send specific guidance on information they need to see in a denial. As this information sometimes differs I will outline general information that I have found to be helpful.

It is first important to note that a denial is typically issued based on the only information immediately available to the FI/MAC, that information being the billing that was transmitted. Denials are often coding errors for the billing or are based upon diagnoses that fall outside the Local Coverage Determination (LCD). The LCD is a document that outlines what the FI/MAC generally defines as meeting criteria for reasonable/medically necessary skilled therapy services. Other denials may be due to a lack of modifier insertion on the CPT billing codes. Denials can also result from inadequate support contained in the documentation submitted in response to an Additional Documentation Request (ADR).

In general, information that is important to incorporate into the denial letter includes:

1. Nursing notes that support the functional level of the patient and the ongoing need for therapy.


2. Physician skilled certifications (for Medicare Part A patients).


3. Documentation from other disciplines that may support cognitive/communicative difficulties experienced by the patient.


4. Dietary consultations that may support the presence of swallowing disorders.


5. Hospital History and Physical to add medical diagnoses that serve as complexities to the case.

An expanded, detailed summary of progress from the start of care should be compiled. The summary should include both objective data and other supporting information that may not have been contained in the original documentation. Think of this process as painting, where the speech therapy services that were rendered are only a part of a larger picture. I try to write the appeal as an explanation of why the services were rendered, what could have happened if they weren't rendered, and what functional outcomes the patient appreciated because of the services.

I usually discourage a senior manager operating independently from the therapist who actually performed the services. Corporate Compliance should analyze the denial and the associated documentation to determine how to best write the appeal. Corporate Compliance writes the denial appeal with input from the therapist and the therapist reviews carefully the completed document. Companies handle the denial process differently so in this situation your experience may differ.

I think it also important to remember that the issuers of denials are not typically therapists. They are trained auditors who determined, for whatever reason, that the services you rendered were not reasonable and/or medically necessary. Writing a detailed appeal letter is our way to explain why we need to be involved with patients.

This Ask the Expert was taken from the course entitled: Documentation for Speech-Language Pathologists Providing Services in Long-Term Care written by Gary Mertz, M.S., CCC-SLP, Director CC/QI Flagship Rehabilitation.

Please visit the SpeechPathology.com eLearning Library to view our courses on a variety of topics in the field.

Gary Mertz, M.S., CCC-SLP has been a practicing Speech-Language Pathologist in long-term care since 1996. He grew in his career through management and now functions as the Director of Corporate Compliance/Quality Improvement for Flagship and Anchor Rehabilitation, Inc.