OIG Enforcement · April 2026

SLP Evaluation Code Upcoding: Why OIG Is Watching 92521–92524

If you're a speech-language pathologist in private practice, your evaluation codes are under more scrutiny than ever. OIG has identified SLP evaluation code upcoding as an active enforcement priority — and the evaluation code family (92521–92524) is at the center of it.

Here's what's happening, why it matters for your practice, and what best practices suggest you do about it.

The Evaluation Code Family: What Each Code Covers

The SLP evaluation codes are hierarchical — each represents a different scope of assessment:

• 92521 — Evaluation of speech fluency (e.g., stuttering, cluttering)
• 92522 — Evaluation of speech sound production (e.g., articulation, phonological processes)
• 92523 — Evaluation of speech sound production AND language comprehension/expression
• 92524 — Behavioral and qualitative analysis of voice and resonance

The key distinction auditors focus on: 92523 bundles both speech production AND language evaluation into a single code. It reimburses higher than 92522 alone — which is exactly why it's an upcoding target.

Why OIG Is Flagging SLP Evaluations

OIG Work Plan data and MAC audit reports from 2025 show a pattern that caught enforcement attention: a disproportionate number of SLP claims bill 92523 relative to 92521 and 92522. In statistical terms, the distribution doesn't match clinical expectations — meaning more SLPs are billing the higher-reimbursement comprehensive evaluation than the clinical population would justify.

The three audit triggers

1. Disproportionate 92523 billing: If nearly all your evaluations are billed as 92523 rather than a mix of 92521, 92522, and 92523, your claims profile stands out
2. Documentation that doesn't support the code level: Billing 92523 requires documentation of BOTH speech sound production evaluation AND language comprehension/expression evaluation. If your eval note only documents one component, the code doesn't survive review
3. Evaluation frequency: Multiple evaluations on the same patient within a short timeframe — especially re-evaluations billed at the same level as initial evaluations — trigger frequency edits

The "Qualified SLP" Ruling: Adding Complexity

The mid-2025 CMS ruling reversing its interpretation of "qualified SLP" has added a new layer to evaluation code compliance. Under the revised guidance, certain services previously billable by SLP assistants or clinical fellows under supervision now require direct delivery by a fully qualified, ASHA-certified SLP. This particularly affects evaluation codes — if an evaluation was conducted by a CF or SLPA without the appropriate level of supervision and oversight, the claim may not be valid regardless of the code level billed.

CMS guidance indicates that practices should review their supervision documentation and ensure that all evaluation services billed to Medicare were delivered by — or under the appropriate supervision of — a provider who meets the current "qualified SLP" definition.

Best Practices for Evaluation Code Compliance

• Match the code to the documentation, not the other way around. Write your evaluation note first, then determine which code the documentation supports. Don't choose the code first and backfill the note
• Use 92522 when that's what you did. If you evaluated speech sound production but didn't conduct a full language comprehension/expression assessment, bill 92522. Upcoding to 92523 because "I briefly assessed language" isn't supported
• Document both components explicitly when billing 92523. Your evaluation note should have clearly distinct sections covering speech sound production findings AND language comprehension/expression findings. A single paragraph that mentions both in passing isn't sufficient
• Track your code distribution. Pull a report of your evaluation code distribution quarterly. If 92523 represents more than 75% of your evaluations, review a sample of those charts to confirm the documentation supports the code level
• Review your supervision structure. Ensure that evaluations billed to Medicare are compliant with the current "qualified SLP" definition — not the pre-2025 interpretation

What Happens When an Evaluation Claim Fails Review

When a MAC auditor reviews an SLP evaluation claim and determines the documentation doesn't support the code level billed, the typical outcome is:

• Downcode: The claim is adjusted from 92523 to 92522 (or another lower code), and the practice receives a recoupment notice for the reimbursement difference
• Denial: If the documentation doesn't support any evaluation code, the entire claim is denied and the full amount is recouped
• Extrapolation: If the review finds a pattern of upcoding across multiple claims, the MAC may statistically extrapolate the error rate across all claims in the review period — resulting in a recoupment that far exceeds the individual claims reviewed

That last point — extrapolation — is what makes evaluation code upcoding a practice-level risk, not just a per-claim risk.