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Building Your Case for Medical Necessity: The Nuts and Bolts of Skilled Therapy Documentation

Building Your Case for Medical Necessity: The Nuts and Bolts of Skilled Therapy Documentation
Melissa Collier, MS, CCC-SLP, CHC, CDP
December 9, 2021

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Editor’s Note: This text is a transcript of the course, “Building Your Case for Medical Necessity: The Nuts and Bolts of Skilled Therapy Documentation,” presented by Melissa Collier, MS, CCC-SLP, CHC, CDP.  

Learning Outcomes

After this course, participants will be able to:

  1. List 3 reasons SLP services are denied by payers in a post-acute setting.
  2. Describe documentation requirements to support the provision of medically necessary services.
  3. Identify examples of skilled therapy services documentation that support medical necessity and meet Medicare requirements for reimbursement.

Post-Acute Payers

Post-Acute Care: Changing Payment Models

Those who've worked in post-acute care for a while know that the changing payment models have really ramped up in recent years.  When I first started, I saw a majority in skilled nursing of that traditional Part A benefit. In the past five years, there has been a ramping up of all of the different payment models. You're seeing a lot of new acronyms.

With traditional Medicare Part A, for the hospital setting, they pay via a Diagnostic Related Group (DRG).  We're not going to get into that in this course.  Our focus is on post-acute care. But they are paid based off of a DRG.

In skilled nursing facilities, the new payment system was implemented in 2019.  It is called the Patient-Driven Payment Model and we are paid via the information that we put on the Minimum Data Set (MDS) which we will review shortly so that we have a foundational knowledge of how we're reimbursing skilled nursing.

Home health also had a new payment model start January 1st, 2020 called PDGM or the Patient-Driven Groupings Model. They are paid via the OASIS assessment which is somewhat similar to the MDS performed in the skilled nursing facility setting.

In addition to traditional Part A, in the post-acute setting, we also treat patients who have Medicare Part B as a payer. Medicare Part B comes into play in the outpatient setting. Also, when you are in a skilled nursing facility setting, we often bill Part B by CPT codes.

Medicaid has also changed. I live in Texas and in recent years we've gone from a Texas government-driven Medicaid system to a Medicaid system being outsourced to managed care organizations.  Some of you may have also seen that shift from a traditional Medicaid system to one that's now managed by managed care or insurance organizations.

There's also been a huge expansion of Medicare Part C, otherwise known as Managed Care. I will discuss how that is really impacting post-acute care shortly.

You may also come into contact with private insurance or commercial insurance plans which have their own rules and requirements. It can be challenging to deal with those individual policies.

Accountable Care Organizations (ACOs) are a new payment model that not everyone in the United States has had to deal with yet. The majority of ACOs are in the east coast right now.  Bundled payments is another payment model for things like joint replacement and there is also Value Based Purchasing (VBP).  However, the current focus has really shifted to outcomes. The goal of all payers is for rehab to be cost-efficient, high-quality care. 

Finally, the IMPACT Act of 2014 was implemented to initiate standardized data across post-acute care settings.  If you are currently working in skilled nursing or in home health, you are probably familiar with Section GG and what that data looks like.  Fortunately, SLPs have not had to initiate that standardized data yet but it is coming.

As I just stated, the impact of Medicare Advantage (MA) plans has really increased in the last few years. Medicare Advantage Plans have grown significantly from about 5.3 million members in 2004 to 22.5 million in 2019.  As of 2021, that number is over 26 million people. That is about 42% of the eligible patients who could receive Medicare services.  

Often Medicare beneficiaries who are choosing Part C, get supplemental benefits that traditional Medicare does not pay for such as dental, vision, other incentives like wellness programs, etc.  CMS works closely with these Medicare Advantage Plans and pays them in a variety of ways. However, payment is primarily based on quality and satisfaction metrics. So, there are a lot of direct financial incentives that are tied to the star ratings for a Medicare Advantage Plan.  Medicare Advantage Plans can be very picky about who they do business with and a lot of that is tied to their star rating.

Medicare Advantage Plans can direct patient referrals. There is a facility in San Antonio that is part of our company and we have a steady stream of one specific insurance company that comes in and out because they just like the way that we work with them. So, we utilize their criteria very strictly and as a result, there's a steady stream of referrals there.

Medicare Advantage Plans also pay different amounts to different providers based on contracting. Sometimes it's based on what the star rating is in your skilled nursing facility or the amount might be tied to what the re-hospitalization rates are or what their quality measures look like. Ultimately, they're looking at outcomes.

Medicare Advantage Plans also have significant involvement in case management. They want to see your documentation frequently, and on a real-time basis. They are always thinking about discharge planning for patients. Essentially upon admission, they start the discharge planning discussion.

As you can see, we still have traditional Medicare Part A and traditional Part B with a little bit of managed care which has really exploded into a lot of confusing and sometimes conflicting information.

Therefore, it is important that since SLPs are providing the services we need to understand eligibility requirements. Those eligibility requirements, in a large part, are the same for managed care organizations. There may be a few caveats but I want everybody to be on the same page as to what the CMS Medicare Benefit Policy Manual says about eligibility requirements and reimbursement criteria.

SNF Part A Eligibility Requirements

For traditional Part A, I am referencing Chapter 8, Section 30 of the Medicare Manual. You can easily google it and find a PDF version on the internet. In order for a patient to qualify for Part A services in a skilled nursing facility, care has to be provided for a condition in which the patient received inpatient hospital services or for which they received services in your facility.

For example, a patient is admitted for pneumonia in a hospital setting and that pneumonia resolves. But, there's an exacerbation of CHF that happens during their Part A stay. The patient would then qualify under this criteria for the exacerbation of CHF because they are in your facility under a skilled stay.

The patient must also require these skilled services on a daily basis and we'll talk about what that means. As a practical matter, considering economy and efficiency, the daily skilled services can only be provided on an inpatient basis in a SNF.  So, there has to be supporting documentation to show why it's not safe or medically appropriate for the patient to return home or to receive care in a different setting.

The services must be reasonable and necessary for the patient's illness or injury. They must also be reasonable in terms of how much they get and how long they receive those skilled services.

Care must be provided under the direction of a physician. For those of you currently working in a skilled nursing facility, you are probably aware of the physician certification that requires the physician to attest that the patient needs skilled nursing services. You're probably also aware that your evaluations must be signed by a physician or a physician extender which, again, supports that physician oversight requirement.

Skilled care must be “medically necessary” and we will discuss exactly what that means.   And, as I just stated, the physician's signature has to be on the plans of care.

Outpatient Eligibility Requirements (Part B)

Part B is slightly different. As previously stated, Part B comes into play in an outpatient setting or in a skilled nursing setting for which the patient does not qualify for Part A benefits.

The first requirement is that the services have to be considered as an accepted standard of medical practice. They have to be considered safe and effective for the patient's condition. The services also have to be so complex and sophisticated that only you, as a licensed clinician, could have completed the service or that the condition of the patient was so complex that whatever treatment you provided could have only been safely and effectively performed by you as a licensed clinician.

Further, the amount, frequency, and duration of the services must be reasonable based on the documentation. The care provided has to be under the direction of a physician. Skilled care must be medically necessary and there has to be a physician’s signature on the plan of care. These Part B requirements are found in the Medicare Benefit Policy Manual: Chapter 15.

Home Health Eligibility Requirements

Home health also has certain eligibility requirements before a patient qualifies for home health services.  These conditions include:

  1. They must be confined to the home
  2. They must be under the care of a physician - again, the physician is required to attest that the patient needs home health services.
  3. They must receive services under a plan of care that is also periodically reviewed by a physician – there must be proof of physician oversight.

They must also need either skilled nursing or therapy services on an intermittent basis. For skilled nursing, remember that it has to be on a daily basis for Part A. For home health, there has to be a solid documentation foundation that the patient needs on an intermittent basis. Meaning, the skilled care is either provided or needed fewer than seven days each week or less than eight hours each day for periods of 21 days or less.

Understanding Skilled SNF Reimbursement

I want to briefly review PDPM because it does play a large role, unfortunately, in how it is discussed that we handle our patients’ plans of care. The old system had multiple Medicare assessment requirements or multiple MDSs. Now we have one. We have an Initial Medicare Assessment plus an Optional Interim Payment Assessment (IPA) if the patient's condition changes. The Initial Medicare Assessment has a seven-day look-back period.  Meaning, it has to be done by day eight and it pays for all of the patient's Medicare Part A days unless the patient changes and an IPA needs to be done.

Patients are placed in a clinical category based on a primary diagnosis that the interdisciplinary team decides on. That primary diagnosis and several other components place a patient into five different components and provide a single daily payment based on the sum of the individual classifications. 

So there are five components and payment is a daily rate. Payment for each component is determined by multiplying a case mix index for the patient's group by the federal base payment rate. Those payments are added together along with the base rate and the facility gets a per diem rate.

Components of PDPM

The components are described below: 

  • PT/OT
    • Primary Diagnosis
    • GG Score
  • ST
    • Acute Neuro Condition as Primary Diagnosis
    • SLP Comorbidity
    • BIMS Scores (<13)
    • Swallow Disorder
    • Mechanically Altered Diet
  • Nursing
    • Diagnoses/Treatments Provided
    • GG Score
    • Depression (PHQ-9 >10)
    • 2 RNPs 6/7 Days
  • NTA
    • 50 Active Conditions with Point Assigned
    • 28 of the 50 require ICD 10 codes listed in 18000 of Section 1 that map to an NTA Component

PT and OT are governed by the primary diagnosis and what the patient's GG score is.  Speech therapy has five components that impact our piece of the pie. Does the patient have a mechanically altered diet or did the patient consume a mechanically altered diet in that look-back period? If the answer is yes, we get credit for that. Does the patient have a swallowing disorder? Swallow disorder is defined in Section K by the patient having interior loss of food or liquid from the mouth, holding food or liquid in the mouth, or having oral residue in the mouth post-swallow. Having a BIM score of less than 13 (so 12 or less) is considered a cognitive impairment, and we get credit for that. An SLP co-morbidity: there's a huge list that if a patient has one of those diagnoses and is placed on the MDS we get credit for that.  Finally, if the facility chooses the acute neuro condition as the primary diagnosis, we also get credit for that.

The sum of those five questions will impact our rate. Our rate, under Part A, is anywhere from around $15 a day, which is abysmally low, to around $100 a day for someone who has all five of those marked on the MDS.

Nursing has their piece of the pie as well as non-therapy ancillary (NTA) which are diagnoses, conditions, and services with weighted points attached. Essentially the more points a patient has based on conditions and services, the higher the NTA reimbursement.

Understanding Part B Reimbursement

Under Part B, SLPs are paid by the physician's fee schedule via the current procedural terminology (CPT) codes which are developed by the American Medical Association.

We have event-based codes and time-based codes. (We'll review the difference between those in a bit.) We also have to use the KX modifier as appropriate. In 2018, the Bipartisan Budget Act repealed the therapy cap, however we do still have to use the KX modifier once a patient reaches a certain threshold that Medicare uses as a medical review process.

We also have the Impact of Multiple Procedure Payment Reduction (MPPR) in which the patient's first CPT code is the highest code and paid in full, and any other CPT code billed that day regardless of discipline is paid at a reduced rate.  We're also dealing with that in the skilled nursing and outpatient settings.

Understanding Home Health Reimbursement

Again, the new payment model for home health is called the Patient-Driven Groupings Model (PDGM) and it cuts payment periods in half.  Home health agencies used to get paid for a 60-day episode of care but that's been cut in half to 30 days. It has eliminated therapy volume as the basis for payment. This is similar to PDPM in skilled nursing except for a couple of different requirements. But ultimately the goal of those new payment systems was to reduce the impact that therapy alone had on reimbursement and really go more toward a patient’s characteristic-focused payment system.

Documentation

What does that mean for our documentation? Documentation is important for so many other reasons other than just your company, agency, or facility getting paid for the services that they're billing:

  • Institutes professional accountability
  • Provides evidence of the patient’s eligibility for skilled services
  • Establishes medical necessity for skilled services
  • Identifies the skilled services provided to the patient, which impacts financial reimbursement.
  • Supports the quality of patient care provided
  • Provides protection against liability risks
  • Demonstrates compliance with state and federal regulations, as well as Practice Act
  • Establishes adherence to standards of practice
  • Assists with communication with team members and physician
  • Promotes continuity of care

It institutes professional accountability. It allows the auditor, the payer, the interdisciplinary team member, etc to show what was medically necessary. What kind of quality care was provided to the patient? It assists with communication that the physician, the PAs, the NPs should be reading. There should be a level of communication that occurs within documentation as well.

But more than just communication, it protects us, as licensed clinicians, against liability risks.  It's important that we document what we do, what we provide to our patients, and how that patient responded to us in cases of liability and in cases of litigation. We have all heard stories about how documentation can make or break a situation like that. Additionally, it demonstrates compliance with state and federal regulations as well as with our Practice Act. And it promotes continuity of care.

I know, as an SLP, I need documentation from the hospital if a patient was seen by speech. I love having the documentation from home health if patients are admitted to me in skilled nursing and I know home health clinicians appreciate what we're able to provide them as well.  So, the better our documentation is the better the continuity of care is.

Think no one reads your documentation?  Think again.

If you think no one reads what you're writing, think again. CMS contracts with a multitude of contractors and it seems that it's become increasingly so in recent years.

  • Medicare Administrative Contractors (MACs)
  • Recovery Audit Contractors (RACs)
  • Comprehensive Error Rate Testing (CERT) Contractors
  • Supplemental Medical Review Contractors (SMRCs)
  • Zone Program Integrity Contractors (ZPIC)
  • Unified Program Integrity Contractors (UPIC)

They have everything from recovery contractors to program integrity contractors. We know that managed care organizations are also significantly involved in documentation review. For me, personally, Humana is one that reviews almost 100% of our claims and that includes our documentation. Sometimes it's on a prepay review where they look at it before they pay us and sometimes it's on a post pay review. But I guarantee your Managed Care Organizations are reading what you're writing.

The Office of Inspector General (OIGs) also has the right to do audits and medical record reviews; and therapy is a focus of those reviews. You may also see state health surveyors in your facilities asking for therapy records. That's another entity that reviews your documentation.

Ultimately, all of these entities have increased their manual medical requests, requests for additional documentation, and the number of denials have increased in an effort to reduce healthcare costs and wasteful spending. Therefore, we have to have documentation in the medical record to counter those denials and to support that medical necessity.

Denials

Why do have denials? Here are a few leading reasons for therapy denials:

  • Documentation not found in medical record or therapy documentation to support coding on MDS, leading to HIPPS codes - For example, the swallowing disorders that I mentioned earlier must be in the medical record if we see those upon evaluation. If issues such as cognitive issues, are not in our medical record, oftentimes, we'll see denials related to that.
  • Skilled therapy services not supported by documentation
  • Lack of Medical Necessity documented
  • Eligibility for Skilled services was not proven
  • Services could have been provided by a Restorative Program or unskilled personnel
  • No documentation to support Homebound status (HH)

Common Documentation Errors

What do we commonly see in terms of documentation errors?  I don't always see a complete and accurate prior level of function, which I will talk about shortly. Goals often lack measurable or functional components. Oftentimes, there's an inconsistency among disciplines, so what you read in the OT evaluation does not match what is in the speech evaluation. I am not referring to individual items that are assessed, I mean discharge plans, the patient's goals, or the patient's prior level of functioning is often different.

Sometimes there's a perception of duplication of services. For example, we are treating cognition and OT is treating cognition. If our goals look pretty similar, Medicare or managed care is only going to pay one of us to do that service. They're not going to pay both of us to perform something that looks the same.

Identical notes from day to day and week to week are also common errors.  Additionally, I often see no progress or very little progress on goals, which is not always a bad thing, sometimes that happens. But there's no documentation as to why or what we did to modify that plan of care. Our evaluations are living and breathing documents. Further, we could document what steps were taken to promote progress and sometimes I don't see that.

Another error I typically see is vague language like “compensatory memory strategies”. There are 100 of those types of strategies and they don't always work.  Which ones did we try, which ones failed, and which ones were successful? What was our analysis of the implementation of those?

The use of abbreviations or colloquialisms that are not universally understood is an error that I see often. I also see a lack of documentation that demonstrates what a patient must be able to do before they can discharge to the next level of care. Managed care often wants to see that. They want to see that we are thinking about how we're going to discharge and when we're going to discharge the patient when we evaluate them. They want to know the barriers to discharge, what skills must the patient be able to do before he or she can return home with home health?  Those should be addressed in our documentation.  Finally, for home health, the lack of vital signs and the lack of documenting a patient's homebound status are common errors and often leading reasons for denials.

Documentation Guidance from CMS

What does Medicare say our documentation should include? This is verbatim from CMS Benefit Policy Manual: Chapter 15, section 230, which governs documentation and it says, “the patient's medical record must include: History and physical exam pertinent to the patient's care, the skilled services that we provided, how the patient responded to those skilled services, any plan for future care based on the results that we've looked at, a rationale that explains the need for that skilled services in light of the patient's overall medical condition and experiences, the complexity of what we're performing as clinicians, and then any other pertinent characteristics of the beneficiary that are going to impact your plan of care.” It also states that the documentation has to be accurate and avoid vague or subjective descriptions of patient care and oftentimes that's the area that I see that needs the most improvement.

Medical Necessity Explained

What does medical necessity mean? Medical necessity is defined in the Medicare Policy Manuals and states essentially that the services are so complex and sophisticated or the condition of the patient is so complex that the services can only be provided by you as the clinician. Medicare reimbursement does not depend on whether or not the patient gets better or what the patient's potential for improvement is but rather did they need skilled care? In other words, what did you do that was so skilled, so complex, and required extensive expertise and knowledge that only you as a licensed SLP could have done what you did?  That is what should be in our documentation.

Components of Medical Necessity

What does that look like? That means our therapy documentation has to include medical and treatment diagnoses that directly impact our plan of care. What other medical complexities or co-morbidities does the patient have to demonstrate their overall condition? Do they have a diagnosis that's going to impact progress, which often happens in post-acute care? Does your therapy documentation support how often you're seeing them each week and how long you're seeing them each session?

Medical necessity also includes the completion of skilled, objective therapy assessments or measurements, either with the use of a standardized assessment or the use of objective data.  Subjective, vague language has to be eliminated from our documentation.

Therapy documentation must show that what we're doing is effective, meaning the patient is going to improve or we are going to mitigate a decline that is needed to maintain the patient's current level of function with patients who have degenerative diseases.  Additionally, therapy documentation has to detail specific skilled therapy interventions to demonstrate why you were needed as a licensed clinician.

I always train therapists by telling them, “Before you sit down to write a progress note, evaluation, or daily note, ask yourself:  What did you do as a therapist that a family member, a caregiver, a nurse, or a CNA could not do and how did the patient respond to you? That answer is the meat of what we should be writing.

To reiterate, Medicare states in Chapter 15 that it is expected that objective measurements are documented to show improvements when they are compared over time. That doesn't always mean that we have to do a full-blown standardized assessment for each progress note. We all know that's not a reasonable expectation. But there should be objective measurements within our documentation to show improvement over time. We can't just write that the patient's getting better, that they're improving, that their memory seems better, or that their swallow has improved. There have to be some objective measurements included. Best practice would be to do a standardized assessment or an objective measurement such as the NOMs, completed upon evaluation and at some regular intervals throughout the plan of care.  If you do a standardized assessment, that scoring sheet should be placed in the patient's medical record. It's not enough to say that a patient scored an X out of X because an auditor or payer will not know what that means.  It is also important to document the interpretation of those results (e.g., "Patient scored X out of X indicating a (fill-in-the-blank) deficit."

Evaluations

Evaluations are the foundation of our treatment. They are, arguably, the most important piece of documentation that we have because they demonstrate the foundational medical necessity for evaluating and treating that patient.

What does your evaluation need to include? First, it needs to include an accurate and thorough prior level of function.  We have to gather as much information as we can about the patient's functional level prior to a recent illness. I recently had a CF ask a patient during an evaluation, “How were you doing right before you came here?” Asking that question causes the patient to think about right before they had a hospital stay, which means they had probably already declined by that point. Therefore, I always like to ask my patients where were you functioning best in the last six months? When were you your best? In the case of a patient who's had a severe CVA, you can wrap that into your documentation.  It’s completely appropriate to demonstrate the patient's overall condition.

Prior level of function is also vital to supporting medical necessity and it serves as the baseline for maintenance plan of care.  If our plan of care is not to get them better but to keep them from declining, then that's when we need to know where their prior level is.

In regards to diagnoses, you have to identify a medical diagnosis, which is the etiology of the deficits that you plan to treat in therapy. A lot of companies will tell you that you also need to add that primary diagnosis on your skilled patients who are under Part A.  In addition to that one diagnosis, it's appropriate to add the etiology of the deficits that you plan to treat. That medical diagnosis can be added as a secondary.  The therapy diagnoses that you choose are the symptoms that have occurred as a result of that medical diagnosis.

Your evaluation also has to include a reason for referral that addresses the specific decline or the patient's risk for decline and how that is impacting their ability to function and how it's impacting their quality of life.

In regards to goals, you must have functional long-term goals, which Medicare defines as the level you expect the patient to be at discharge. You must also include short-term goals which are those incremental steps toward the long-term goals. Additionally, goals should be patient-specific, measurable, and functional.

We want to thoroughly assess the patient's condition. We want to include a clinical impression or justification to outline, from our clinical perspective, what the overall deficit areas are, how treatment will impact those deficits, and what the patient has to do in order to return to their prior level of function or transition to the next level of care.

Home Health Evaluations

For home health, we need to include vital signs. It is always best practice even in skilled nursing - especially in the world of COVID -  to include vital signs.  In home health, we also need to document the patient's homebound status. For example, are caregivers available and how often? What are the barriers in the home? Driving and the ability to drive should not be recorded as part of the homebound status documentation per home health agency guidance. There are rare exceptions, but in general, home health frequency of services typically do not exceed three times a week.

Writing Goals

When writing goals, as a reminder, they must be patient-specific, measurable, and functional.  In order to set a functional goal, we need to ask ourselves a few questions:

  • What: What does the patient need to accomplish?  What do they need to improve? What do they need to decrease their risk of?
  • Where: Should the goal be specific to a location or a circumstance? If a patient's showing inattention to tasks and, as a result, they're losing weight should the goal then be focused on increasing sustained attention to task during a meal? That is more patient-centered and more patient-specific.
  • Which: Are there any requirements or constraints that need to be added to the goal? Are we talking about unfamiliar listeners, familiar listeners? Are we doing this in a structured environment or an unstructured environment? Are we looking at carry over opportunities?
  • Why: Why are we writing the goal? What is the reason that the patient needs to accomplish the goal?  What aspect of quality of life is going to be impacted by improving the deficit area?

Short-term goals should be achievable in 2-3 reporting periods. It is a more incremental goal of where you want the patient to be in two to three weeks.  Whereas, long-term goals should be achieved by the end of the plan of care. They can be broader, more encompassing goals.

Short-term goals and long-term goals should correlate.  For example, if you want a patient to reach a certain level in two to four weeks, what level do you want them to reach in the same deficit area upon discharge? For a short-term goal, you could write, “The patient will improve speech intelligibility of functional phrases (that's our hierarchy) and the long-term goal is for the patient to be intelligible at a conversational level with partners in order to participate in conversational exchanges.

What should not be included in our goals? Interventions shouldn't be included. For example, “The patient will complete oral motor exercises 2x10 sets. That is an intervention to reach a goal. What is the purpose of doing those oral motor exercises? Is the goal to improve lingual coordination for bolus control? Is our goal to have no oral residue post-swallow? If that's the ultimate goal and we're doing that via lingual oral motor exercises, then our goal should be “improved lingual coordination” or “the lack of oral residue presence.”

Your plan for treatment should not be included in the goals. I often see, “develop a restorative program.” That's your plan, that's not a goal for the patient. Instead, write a goal that says, “Patient will participate in a restorative program for communication as evidenced by 100% return demonstration by caregivers in order to improve patient communication with staff and peers.”

Another thing that should not be included in our goals is anything that is outside of our scope or anything that is not considered to be skilled. An example would be, “Patient will lose zero pounds in 30 days.”  That shouldn’t be a goal of therapy.  Instead, we could say, “Patient to follow three-step commands with 75% accuracy in order to improve ability to participate in self-feeding activities to increase PO intake.”

Sometimes, I see a self-feeding goal that SLPs have written. Let OT handle hand-to-mouth self-feeding. We need to focus on either the dysphagia component which impacts PO intake and weight loss or the cognitive-communicative aspect of treatment that also impacts weight loss.

Goal Examples

Here are some examples of patient-specific goals. The goal has a measurable component, and at the end of every goal there is a functional reason, or quality of life impact, for each of those goals.

  • Auditory Comprehension: Patient will follow multi-step verbal commands with 100% accuracy to increase his ability to complete hygiene and grooming tasks independently.
  • Dysphagia: Patient will exhibit minimal pocketing as evidenced by clear oral cavity 100% of attempts while consuming puree consistencies and nectar thick liquids in order to decrease risk of aspiration.
  • Sustained Attention: Patient will attend to a meal in her room for a duration of 30 minutes with occasional cueing by caregiver and environmental modifications in order to increase PO Intake and reduce risk for further weight loss.
  • Short Term Memory: Patient will verbally recall steps needed to access his address book on his phone with 100% accuracy independently in order to improve his ability to make doctor appointments.
  • Verbal Expression: Patient will name objects in her immediate environment with 90% accuracy in order to improve her ability to effectively communicate her wants and needs with staff.

Skilled Justification for Therapy: Evaluation Example

Here is an example for a skilled justification, which essentially is a summary of your clinical impressions of the patient and how that impacts their quality of life.

Patient is a 61-year-old male s/p cerebral infarction with PEG placement that occurred during hospitalization. Patient presents with severe oropharyngeal dysphagia, characterized by reduced oral motor strength, ROM and coordination on the left side, reduced hyolaryngeal excursion, and absent cough despite runny nose, watery eyes, and gurgly vocal quality post saliva swallow. Patient has documented aspiration on all consistencies from MBSS performed during hospital stay. Patient will benefit from skilled ST to improve swallow function and decrease aspiration risk. Medical comorbidities include left-sided hemiparesis, cognitive deficits secondary to CVA, and history of TIAs, all of which may impact his rate of progress with therapy.

Progress Notes

The next piece of documentation is progress notes. Every progress note must include the following per the Medicare Benefit Policy Manual, Chapter 15:

  • The assessment of improvement, extent of progress (or lack of progress) toward each goal;
  • Plans for continuing treatment, reference to any evaluation results, any modification to short or long-term goals should be documented;
  • Documentation to support that the skills of a licensed therapist were required. This, in my opinion, is the most important piece.

What does this look like from a practical standpoint?  First, all of the goals should be addressed. However, sometimes that's not possible. If you cannot address the goal, then there needs to be a statement of why you didn't address the goal in that reporting period.

If you didn't make progress on a goal, and sometimes that happens, then include documentation to support your analysis of why. Did the patient have a recent medication change or a recent, new diagnosis? Are they on antibiotics for something? Are they depressed? Are they showing a decline because of prolonged isolation in their room due to COVID precautions? What is your interpretation or analysis of why they have not improved? What are you planning to do about it?  Are you planning to modify your treatment approaches? Are you planning to treat them in the gym versus in their room? Are you planning to do a social distance group to improve their social interaction if appropriate? Are you planning to try a different time of day or a different treatment technique? Are you trying to build rapport with the patient or do some education? What are you trying if no progress has been made?

If you still haven't made progress in 1-2 reporting periods, you may want to consider breaking the goal down into a smaller, more incremental component or changing the goal. Remember, the plan of care is a living and breathing document. Therefore, as the patient changes so should your treatment plan.  There must be documentation to support what the therapist did that was skilled.

Home Health: The Visit Note

For home health, each note has to stand alone. Each visit note is essentially a summary of what you did during the visit and the patient's response to what you did.  It must be written on the day that the visit was performed and the patient or the responsible party must sign the visit note.

The medical necessity requirements are the same as previously discussed, but you do need to document vital signs, pain assessment, any shortness of breath, use of assistive devices in the home, and prove that the homebound status has been met every time we write a visit note. 

The visit note must also include what skills, knowledge, and/or expertise you used and any future plans or coordination that you provided for the patient’s continuity of care.

Documenting Homebound Status

Below is how to document homebound status and, fortunately, our software systems have these criteria built-in, and likely, requires you to document this before you can close out your visit note.

The patient MUST meet both Criteria 1 and Criteria 2 as written below:

Criteria 1 is an  “OR” statement.

A.       Requires aid of supportive device or special transportation ( ie. ambulance) or assist of another    (describe/explain) _______________________________

                                                            OR

B.      Leaving home is contraindicated medically    (describe/explain)__________________________________

                                                            AND                                                          

Criteria 2 is an “AND” statement and three parts long.

A.      There exists a normal ability to leave home    (describe/explain)_______________________________________  AND

B.      Leaving home requires a considerable taxing effort    (describe/explain)__________________________________AND

C.      Absences from the home are infrequent, relatively short in duration or to receive medical care     (describe/explain)____________________________

Always fill in the "(describe/explain)____________” section, as it is how we individualize our responses to capture fully the unique client that is in front of us—otherwise, it may appear to Medicare that we are answering the same exact way for every single person which, to them, would be not ideal.

When discussing and documenting homebound status, it’s important to think about their living situation. Do they live alone? Do they live with someone? What's the availability of their caregivers? What kind of residence do they live in? What do they need to be able to do in order to safely live in their environment? Are there any physical or environmental hazards that need to be addressed?  Are there any precautions that you, as the clinician, are having to abide by? What is their mental status and is that changing over time?

Here's an example of documenting that skilled service in your progress note:

Implemented thermal tactile stimulation techniques pre-swallow to increase timeliness of swallow initiation, instructed in completion of laryngeal adduction exercises to protect the airway, and provided training in the use of second dry swallow to increase swallow safety. ST assessment of swallow during mealtime noted increased timeliness of swallow initiation post stim. Patient required consistent verbal cues to complete 2nd dry swallow to clear residue.

You see a lot of verbs in that example and I always say if Medicare and managed care payers want to know what you did. Did is a verb.  You need to take credit for what you did and how the patient responded to that skilled treatment.

Re-Certifications

 Re-certifications are the next piece of documentation, and per Medicare, they have to be completed at least every 90 days. That timeline may change with each Managed Care or Medicaid Organization. It may also change with your specific company requirements. Re-certifications, also called UPOCs (Updated Plans of Care) must be signed by the physician to show evidence of that continued physician oversight.

Re-certifications can be completed early, at least every 90 days, if a plan of care needs to be significantly adjusted or modified. It is okay to open up that re-certification early,  update those goals, add those CPT codes, update the treatment diagnoses that may have changed to prompt the physician to re-review it and sign as proof of physician oversight.

The re-certification summarizes the care since the evaluation or the last re-certification. It also shows support for why we, as clinicians, feel that the patient needs continued treatment.

Below is a summary example of documenting skilled services.

Since evaluation, this patient has received skilled speech therapy, focusing on improving intelligibility with unfamiliar listeners. During the course of therapy, ST implemented techniques to improve volume of speech and over-articulation of words and phrases.  ST also educated patient on phrasing and reduced rate of speech. ST to create a home exercise program to continue carryover of diaphragmatic breath control and voicing techniques, as patient is expected to be discharged home in 2 weeks.

Anytime I do a re-certification, I like to include about three sentences basically stating, "since the evaluation, this is what we've done throughout the course of treatment, this is what I did as a skilled licensed SLP" and then what my plan is or why they need continued therapy.

Daily Treatment Encounter Notes

Daily treatment encounter notes are important to show a patient’s specific idiosyncrasies that may change daily or trial and error attempts that you might be doing in your treatment. Some companies may not require a daily treatment encounter note every day, but the Medicare Benefit Policy Manual Chapter 15 states that there needs to be daily documentation, if appropriate, for:

  • A patient self-report
  • Anything negative that happened in response to intervention
  • Any communication/consultation with a provider – For example, if you consult with a PT about a patient’s ability to get in wheelchair on his own and he’s not able to, that communication should be documented.
  • Any significant, unusual, or unexpected changes in clinical status. Meaning, if you're taking O2 sets and notice a drop that should be documented.  Then, subsequently, if you communicate that change with a nurse, you should also document that as well.
  • Any equipment that you provided or anything that you may have provided the patients such as a home exercise program that should be documented as well.
  • Anything else relevant that you feel is appropriate to add in the medical record should also be documented.

Again, daily treatment encounter notes are not always required across the board per company but it is important that if a patient complains of pain and location, that we document that as part of the interdisciplinary team. Any reports that you gave to nursing should also be documented. Any objective measurements that you complete (e.g., percentages, the number of items correct, trials completed, etc.), specific interventions or techniques and their effectiveness. Don't just say “memory strategies”. Indicate which ones you used.  Did you train in mnemonics or in visualization?  Were you working on spaced-retrieval training? Were you working on implementing a visual aid such as a calendar or a planner? What exactly were you working on?

For example, I know mnemonics don't work for me. Association works for me and visualization works for me. I have normal cognitive abilities most of the time. I'm a mom so it does kind of fluctuate and I need a planner.  But a planner doesn't work for my husband. So, you have to document that level of specificity when you're doing your daily treatment encounters. It's okay to take acknowledge your failures because that implies that you're performing a critical analysis of what's working, what's not working, and adjusting your treatment accordingly.

Daily treatment encounter notes can also include any cueing you provided, how the patient responded to you, what your plan is for the next treatment, and then any other communication or education that you may have provided.

I like to use the acronym TAP when I do my daily notes. I write the Treatment or Technique I provided, my Assessment of whether or not it worked and the type of cueing I had to give them. And, lastly, the Patient's response. Were they 50% with cues? Did they improve from 30% without cues to 80% with cues? What was the improvement level?

Here's an example of a daily treatment encounter note:

Implemented spaced retrieval training technique to improve patient’s ability to recall room number. Provided cueing hierarchy and visual aid to increase recall of how to locate dining room, patient’s room, and activities. Patient able to recall room number in 6/10 trials and was able to utilize visual aid to locate dining room with minimum cues during this treatment.

Discharge Summary

The discharge summary is the final piece of documentation and it's essentially the last opportunity to justify the medical necessity of the services that you provided because it summarizes the entire episode of treatment.  Sometimes it can be tricky to try to summarize in a few sentences all that you did for the patient, but it's really important.

A lot of managed care companies and many auditors don't have much time to review a medical record.  Many times, they will look at your evaluation and your discharge summary. Sometimes, whether we like it or not, they make a decision based on what we documented on those two pieces of documentation. So, the discharge summary is a really important piece of documentation.  Ultimately, the therapist must justify their skilled services in a discharge summary.

Here's an example of what a summary might look like in your clinical impression section or your summary of treatment approaches:

Treatment since evaluation focused on improving overall swallow function. Upon eval, patient was on an ordered diet of puree textures and moderately thick liquids after a hospital stay for pneumonia and COVID19. Skilled ST implemented lingual and labial oral motor exercises, instructed in Shaker exercise to improve hyolaryngeal movement, trained in safe swallow strategies (effortful swallow, chin tuck and slow rate of intake), and trialed mech soft and mildly thick liquids with analysis of swallow. As a result of treatment, patient’s diet was upgraded to mech soft and mildly thick liquids. Swallow function has improved from severe to moderate. Caregiver training was completed and a swallow RNP was developed, with RNA John demonstrating interventions at 100%.

I had a dysphagia professor in graduate school that always said, and it has stuck with me forever, “If you did not document it, it did not happen.” And that is just the truth. I know documentation is not everyone’s favorite thing to do, but it is vitally necessary.

Method for Documenting Skilled Services

You've heard of soap notes, but I like “soapier” notes. I like to utilize that acronym and this is what it means:

  • Subjective data - How is the patient doing? How are they feeling? Did they report anything that was important to you?
  • Objective data - What objective measurement did you use? Percentages, trials? Did you do a standardized assessment or a portion of a standardized assessment? That's important.
  • Assessment - What did you evaluate? What did you assess? What kind of feedback did you provide?
  • Plan - Are you going to do anything different in future treatments? Is there a plan there?
  • Interventions - What techniques or cueing or skill or education did you implement as the clinician?
  • Evaluation – What was the patient's response to you?
  • Revisions - Did you do any revisions?  What did you do to modify or adjust your techniques, level of cueing, or overall plan of care?

This is not to suggest that every one of these must be documented every single day. But you should consider these before you write a note. I understand that in reality, we don't always have a lot of time. But we do need to learn how to work smarter and not harder. Utilizing those questions will allow your documentation to have less fluff and more meat; and that's ultimately what you want.

Skilled Language Examples

Below is a list of skilled language examples.  In this list, I use a lot of verbs in my skilled language. Again, if the payer or reader wants to see what we did that no one else could do, I am going to include action verbs in my documentation.

  • Analysis of deficit area (be specific)
  • Completion of objective measurement and analysis of results
  • Implementation of adaptive equipment
  • Implementation and analysis of new skill learned
  • Identification of targeted muscle groups during exercises
  • Development and implementation of techniques or compensatory strategies (be specific - which strategy was used?)
  • Analysis of functional outcomes
  • Assessment/evaluation of skills and carryover outside therapy environment
  • Creation of individualized treatment
  • Analysis of complexities/conditions/comorbidities that impact progress/therapy
  • Modification to technique, strategy, plan of care to ensure success
  • Analysis of hierarchy of tasks
  • Provision of skilled teaching or feedback
  • Education provided to patient, family or caregivers
  • Customization of equipment
  • Documentation of trials and analysis of patient's response

Remember, it’s ok to trial something and if it doesn’t work that is okay.  Take credit for that failure and document what you plan to do in the future. This is not an all-encompassing list. You can probably think of 1,000 other verbs that may be just as medically necessary to include.

Unskilled Language Examples

Moving on to unskilled language examples, what do we frequently see in denied claims?

  • Doing well
  • Minimal, slow, or no progress without rationale/analysis
  • Tolerated treatment...
  • Increated ROM or strength
  • Chronic condition
  • Stable or stabilizing
  • Verbs like 'Monitored, Discussed, Observed'
  • General weakness
  • Debility
  • Not cooperating, not motivated, refuses to
  • Max cues for participation
  • Maintaining
  • 'Pt seems to be' or 'appears to be'
  • Drills/exercises, such as 'OM ex x 10' or 'answered recall questions with 90%'
  • WNL/WFL
  • Endurance/activity tolerance without tying it to a function
  • Repetition
  • Unable to learn/inability to retain info
  • General terms like 'good/fair/poor'

We see phrases like, 'Doing well, doing okay, doing poorly, they have minimal progress, etc.' One thing that I see, especially in recent years as our patient populations have become younger with sometimes more psych diagnoses, is the “non-compliance” or “patient was not compliant with care.”  Be very mindful when you use the word non-compliant over and over again in your documentation. There's a perception that you should not be involved if you're not doing anything skilled and the patient doesn't want you there. Instead, you should take credit for any education that you provide, for any assessment that you perform, or for any treatment that you provide.  Of course, be sure to document barriers, challenges, or diagnoses that are going to impact that plan of care. That is very important.

We live in a “patient rights” world right now and, as a result of that, Medicare has changed their policies and their F-tags to really include patient responsibility, patient choice, patient involvement, etc in their plan of care. So, again, it's very important that we document what we did and what the patient's response is.

Be very mindful of the word “non-compliance” and the implications of that. Other unskilled language includes, 'chronic,' 'chronic condition,' 'stable,' 'monitored,' 'I monitored a patient at a meal.'  You, as an SLP, don’t need to be paid to monitor a patient.  You are assessing them or you're analyzing their abilities. Those are more skilled words to use.

Another example of unskilled language is, 'I observed the patient eat a meal.' Let's use a different word. 'Not motivated' or 'refuses' are unskilled words.  Instead, what did you try to mitigate that? Did you educate? Did you build rapport? Did you redirect? Did you try a different time of day? Take credit for your tries. Some patients are not motivated and some patients are going to refuse. That just happens and that's okay. Your plan of care will likely be short with those individuals.

Another example, patient 'seems to be' or 'appears to be' doing well.  That is very subjective language and Medicare wants that subjective language out of our documentation. Instead of documenting, 'oral motor exercises times 10,' what specifically were you working on? Use that skilled language by identifying those targeted muscle groups. Also, by writing, 'answered recall questions with 90%,' or 'patient performed…,' you're taking yourself out of the treatment if you're documenting patient performed instead state what you did and how the patient performed as a result of your skilled treatment.”

'Within normal limits' or 'within functional limits,' are other examples of unskilled language and can be seen as subjective. Documenting objective measurements is important.

In regards to repetition, if your notes look the exact same every day (e.g., 'patient did auditory comprehension tests' or 'patient did a reading passage and answered questions.') then that negates the skill. 

Similarly, if you have a software system at your facility that has phrases built in and you document those in the same order every single time you do a note, that also negates the skill.  I even had an administrative law judge say, “I can tell they're just clicking buttons.”  So, make sure that what you're selecting in your software system is a true and accurate reflection of what you did.  Also, if you are able to free tap a sentence or two to make it more patient-specific, then do that because that makes the document more medically necessary.

General terms like 'good,' 'fair,' or 'poor' tend to be subjective and we want more objective data.

Jimmo vs Sebelius

This case has come up several times recently even though the clarification came out in 2013. Hopefully, you are familiar with the Jimmo versus Sebelius case in which several groups and individuals sued Kathleen Sebelius, who was a Health and Human Services secretary, over the false claim that Medicare administrative contractors and other contractors were denying claims based on lack of progress. Mrs. Jimmo and the other individuals who were involved with that lawsuit stated that the contractors couldn’t do that because the Medicare manual states that they don't have to make progress, they just have to need skilled care. And that is true.

As a result of that lawsuit, Medicare didn't have to add anything, but they had to clarify their policy that states Medicare coverage does not depend on whether the abilities are going to be restored, but rather on whether skilled care is required. Is it medically reasonable? Is it medically necessary? Therefore, we have to provide sufficient documentation to substantiate to Medicare that skilled care is required.

The question I always get is, “Does the patient have to show progress in order to receive speech-language pathology services?” The answer is, “No," but they do have to have a degenerative disease or diagnosis, and we must show that our services are needed to prevent a decline or to maintain the patient's current level of abilities.

Billing and Coding

Billing and coding is just as important as documentation. I wanted to review our billing and coding guidelines so that everyone can feel confident that their billing and coding is correct.

Evaluation Codes Defined

We have one evaluation code for the Evaluation of Oral and Pharyngeal Swallowing Function, and that is 92610. The definition of that evaluation code is:

Dysphagia, or difficulty in swallowing, can cause food to enter the airway, resulting in coughing, choking, pulmonary problems, aspiration or inadequate nutrition and hydration with resultant weight loss, failure to thrive, pneumonia and death. It is most often due to complex neurological and/or structural impairments including head and neck trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, dementias, and encephalopathies. For these reasons, it is important that only qualified professionals with specific training and experience in this disorder provide evaluation and treatment.

Swallowing assessment and rehabilitation are highly specialized services. The professional rendering care must have education, experience and demonstrated competencies. Competencies include but are not limited to:

  • Identifying abnormal upper aerodigestive tract structure and function
  • Conducting an oral, pharyngeal, laryngeal and respiratory function examination as it relates to the functional assessment of swallowing
  • Recommending methods of oral intake and risk precautions
  • Developing a treatment plan employing appropriate compensations and therapy techniques.

I find it interesting that the definition also adds competencies with the four bullet points. 

92610 is our evaluation for swallow function code. It is any event-based code, meaning that for the purposes of CPT billing or Part B billing, you bill that code and it gets paid one time regardless of how much time you put in. There are some company directives that provide guidance on how long or how little they want you to bill. However, from a Medicare and managed care perspective, there are no time requirements.  You get paid the same amount for 92610 when you bill 15 minutes as you do when you bill an hour. The amount of time should be dictated by the medical necessity of the evaluation and should be at the clinician's discretion.

Speech-Language Evaluation Codes

  • 92521 is the code for the evaluation of speech fluency, (i.e., stuttering or cluttering). We don't see a lot of that in post-acute care although sometimes it's necessary.
  • 92522 is the code for evaluating speech sound production which includes articulation, phonological processes, apraxia, and dysarthria.
  • 92523 is the most commonly billed speech-language evaluation code and is the evaluation of speech sound production and evaluation of language, comprehension, and expression, which does include the cognitive-linguistic component.

I  am often asked, “If I'm looking at memory, can I bill it under 92523 if I'm including that in my assessment.” The answer is, yes, because 90% of the time we're utilizing expressive and receptive language to assess memory abilities which falls into the cognitive-linguistic component.

Time-Based Evaluation Codes

There are a couple of time-based evaluation codes that your company may have a policy on whether or not they would like you to use them based on your local coverage determinations, history of denials, and things of that nature.  But it is part of our CPT code structure that we, as SLPs, can bill them.

  • 92626 is evaluation of auditory rehab status the first hour, and then there's a separate code for each additional 15 minutes.
  • 96125 is frequently used in skilled nursing and is called a standardized cognitive performance test. The definition states “per hour” and there are strict criteria on when you can bill this code. You have to use a standardized assessment. Assessments such as the SLUMS, the MoCA, the ACE do not count. The scoring record has to be added to the patient's medical record and it has to be at least 31 minutes or longer before you can bill that code as well. So, there are definitely some requirements before you can bill standardized cognitive performance testing.
  • 96105 is the code for assessment of aphasia, which includes assessment of expressive and receptive speech-language function with interpretation and report, per hour. Again, it has to be billed at least 31 minutes and you have to do a full standardized assessment with a record sheet available in the medical record.
  • 92607 is the code for an evaluation for a prescription for a speech generating device, face-to-face with the patient, first hour. Again, that code alone has to be billed at least 31 minutes in order to bill 92608 which is the additional 30 minutes. You have to put 60 minutes under 92607.
  • 92524 is for voice evaluation. If you are assessing voice only that's the code to use.

These codes are also event-based meaning the facility is reimbursed at a one-time rate regardless of the amount of time that you, as the clinician, bill. Again, it should be based on the thoroughness of your evaluation which should be supported in your documentation. But there is no time requirement for these codes.

A question I often get is, “Can I bill a speech-language evaluation and a swallowing evaluation on the same day? And the answer is, “Yes.” Currently, there's no restriction on an SLP’s ability to bill the codes together because there are certain circumstances when that’s appropriate. Your documentation just has to reflect two separate billing codes and a complete and distinct evaluation for both speech and language and for dysphagia. Again, all five of those evaluation codes are event-based. You get one payment regardless of the time billed under that code.

Treatment Codes

SLPs are pretty lucky in that we do not have a ton of options like our PT and OT peers which makes it a little easier to remember which one is which. 92507, 92508 and 92526, for the purposes of Part B billing, are event-based codes. 97129 and 97130 are cognitive development codes and are time-based.  

  • 92507 code is for general speech and language, voice, communication, which can also include the cognitive-linguistic component
  • 92508 is the group therapy code
  • 92526 is our swallow treatment code
  • 97129 and 97130 are cognitive function codes. For Medicare purposes, most Medicare local coverage determinations allow for SLPs to bill these two codes in the post-acute care setting. But, many managed care organizations do not allow you to bill these codes

Therefore,  it's important to check with your supervisor, your director, your billing manager to see if cognitive development is reimbursed. Many managed care organizations have a requirement that in order to bill that code there has to be an expectation of improvement in a relatively short timeframe and they have to have a recent diagnosis with a neuro basis, such as a CVA, TBI, or a closed head injury. So, be sure to check with your facility to get some guidance on which ones will let you bill it and which ones will not.

Timed or Untimed?

For the purposes of CTP billing (i.e., Part B billing), 92507, 92508 and 92526 are untimed. They're event-based.  You bill them one time and whether you see them for 15 minutes or an hour, the reimbursement is the same.

The CPT codes that are timed and we are able to report are the cognitive development training initial 15 minutes (97129) and the cognitive development training subsequent treatment (97130). It has to be reported in conjunction with that initial 15-minute code. For example, for 22 minutes of treatment you would bill 97129 for 22 minutes. When you bill per unit, eight minutes to 22 minutes is one unit. So, if you are only planning to bill one unit then 97129 would be billed for the entire time. Once you hit 23 minutes, you are now in two units.

Another example is you have 23 minutes of cognitive development treatment. Then you bill 97129 for 15 minutes and bill 97130, that subsequent cognitive development, for an additional eight minutes. You have to abide by the eight-minute rule when you're billing the cognitive development codes.

Another question I often get is if you can bill 92507, which is speech-language treatment and cognitive-development treatment, on the same day. The answer is no. Chapter 11, Section H-3 of the Medicare NCCI Policy Manual states that a practitioner cannot bill 92507 or 92508 on the same day as the cognitive development codes. It also says that you cannot report those codes 97110, 97112, 97150, 97530 as unbundled services if you bill event-based codes, speech-language therapy group therapy, or swallowing therapy.

Another question: Can you bill 92508 for dysphagia group treatment? ASHA states that 92508 is used to report group therapy for speech-language, voice, communication, and or auditory processing disorders. Currently, there is no CPT code to describe group therapy for dysphagia. They refer to the local coverage determination or your Medicare administrative contractor for guidance. Some Medicare administrative contractors do allow you to bill 92508 for anything under the scope of practice for SLPs. Others do not. Some allow you to bill the 97150 group code for swallowing group therapy.

You really need to refer to your company based on where your state is and what local coverage determination you have to abide by that. That is really going to determine how you can bill it. Ultimately, it's a gray area that is specific to the local coverage determination and your contracts for managed care companies.

Have you Built Your Case for Medical Necessity?

To conclude, moving forward, I hope that you can ask yourself these questions after completing a document and feel really comfortable answering yes:

  • Do I adhere to the CMS requirement of the use of objective measurements?
  • Can others understand my documentation?
  • Would someone who doesn’t know the patient get a full picture of that patient through my documentation?
  • Would my documentation stand up to a Medicare audit?
  • Would my documentation defend or protect me in court?
  • Would all of my treatments be reimbursed as medically necessary?
  • Does my documentation demonstrate why my skills, knowledge and expertise were required?

If you can confidently say, “Yes,” to these questions then you're definitely on the right track.  If you can't say yes to all of them, then you know where you need to improve. Hopefully some of the things that we talked about in this course can help you improve in these areas a little bit at a time. That would be the goal.

Questions and Answers

In order to support medical necessity, would you suggest that documentation report all of the patient's progress in percentages? I guess as opposed to cueing levels or some other measure of progress?

It really depends on what you're measuring. If you're measuring a patient's ability to verbally express functional phrases and sentences, then I think a percentage level is appropriate. You can always incorporate percentages, number of trials, etc. There are times when some goals, like swallowing goals, get a little bit in the weeds because we may not know how to make that measurable. I think that the use of “less than one sign or symptom of aspiration,” or “zero in a meal” or zero in a specific timeframe, is appropriate.  As long as you add a number, whether that be a percentage, a trial, a number of minutes, then you're on the right track. I don't know that you have to do it in a percentage always though.

Why are we often asked to evaluate and treat the same patient in the same day? Is that always called for?

I think that sometimes a company has policies and procedures in place that they feel are best practices for their clinicians in order to meet medical necessity requirements. I will tell you that from a guideline perspective and a Medicare Benefit Policy perspective, there is no requirement for evaluation and treatment on the same day.

Do you know of any standardized assessments that are not accepted for evaluation when a review takes place? Also, for 96105, does the entire Boston, Western, etc. need to be administered for that code?

According to the definitions for assessment of aphasia, the manuals don't say you have to complete every single bit of it. It says a full standardized assessment must be completed. So, if you have a patient who is unable to complete a one part of it and you feel that according to the service you provided the code that most accurately reflects your evaluation is 96105, as long as you can include that record form I think that you would be okay. As a routine, billing that code and just doing your favorite subsets because they take the least amount of time would not be acceptable.

To answer the question, “Is there one that's not appropriate,” if it's a screening tool - even if it's a standardized screen - those do not count. But I do not know of any full-blown standardized assessment that would be denied.

I know you have a certification in Healthcare Compliance and you do a lot of that type of thing for your company. How did you get into that? It’s something I’d be interested in getting into since I’ve been in the SNF setting for a long time. Can you share how you moved from more strictly clinical speech-language pathology into your current position? Any training that you got or hints you might offer for her?

It was a little bit of happenchance for me. I was also a rehab director. I actually became a rehab director as a CFY which was unusual. So, I've always been pretty heavily involved in operations. My boss, who was a regional manager at the time, was writing denials and appeals for a company that I worked for and I asked if I could take over or learn from her. So, she took me under her wing. I also love to read and if you really enjoy reading, my advice would be read any blog, any subscription that you can get from CMS or insurance providers.  Subscribe to all of them.  Look for opportunities to assist in the denials and appeals if you're able to do that. Offer to write a clinical program. A lot of times we get into a rut as clinicians or as directors and I encourage you, especially in this time of COVID, to think outside of the box. Take some initiation and say, “I want to write a program.” That's what I did as a regional director I said that I wanted to write dementia program. So, I got a couple of dementia certifications and just did it. That would be my biggest recommendation - take some initiative and do something that someone is not expecting you to do.

Of course, the certification is Healthcare Compliance is huge. If you are interested in the education piece, get your RAC certification I'm getting mine before the end of the year it's on my to-do list.  Any certification that you can get is always going to help with apply for jobs. If you have the personality that would fit a job like that, I recommend you apply. I don't think that we, as SLPs, don't take that leap of faith quite as often and we should.

In Iowa, for our intermediary, at the beginning of 2020 the requirement to bill 31 minutes with code 96125 went away.

That's good to know. Yes, so if you're in Iowa you do not have to worry about the 31-minute requirement.

References

American Speech-Language-Hearing Association. (2020.) Documentation of Skilled Versus Unskilled Care for Medicare Beneficiaries. Retrieved from http://www.asha.org/uploadedFiles/Documentation-Skilled-Versus-Unskilled-Care-for-Medicare-Beneficiaries.pdf

American Speech-Language-Hearing Association. (2021.) Examples of Documentation of Skilled and Unskilled Care for Medicare Beneficiaries. Retrieved from https://www.asha.org/practice/reimbursement/medicare/examples-of-documentation-of-skilled-and-unskilled-care-for-medicare-beneficiaries/#skilled-unskilled.

American Speech-Language-Hearing Association. (2021). Group Treatment. Retrieved from https://www.asha.org/practice/reimbursement/medicare/grouptreatment/.           

CMS. Medicare Benefit Policy Manual. (Updated 3/24/2021). Covered Medical and Other Health Services. Chapter 15, Section 220.2 C&D and Section 220.3. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

CMS. Medicare Benefit Policy Manual. (Updated 10/4/2019). Covered of Extended Care (SNF) Services Under Hospital Insurance. Chapter 8, Section 30. Retrieved from https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c08pdf.pdf

CMS. Medicare Benefit Policy Manual. (Updated 11/6/2020). Home Health Services. Chapter 7. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf.  

CMS. Jimmo v. Sebilius Settlement Agreement Fact Sheet. (5/31/20). Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf

CMS. National Correct Coding Initiative Policy Manual For Medicare Services (Updated 1/1/2021.) Retrieved from https://www.cms.gov/files/document/chapter11cptcodes90000-99999final112021.pdf

Finkel, C. (2017, Jan-Feb.). Changing Payment Models: Shifting Focus on Post-Acute Care. Mo Med.  114(1): 57–60.

Kinder, R. (2017, Sept 21-23.). Writing Person-Centered Functional Goals. Kansas Speech-Language-Hearing Association Convention. Retrieved from https://ksha.org/docs/SLP5_Writing_Person_Centered_Functional_Goals.pptx/.

Citation 

Collier, M.(2021). Building Your Case for Medical Necessity: The Nuts and Bolts of Skilled Therapy Documentation. SpeechPathology.com Article 20492. Available from www.speechpathology.com

 

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melissa collier

Melissa Collier, MS, CCC-SLP, CHC, CDP

Melissa Collier received her Master's degree in Speech-Language Pathology from Texas Christian University and actively holds a Certification in Healthcare Compliance. She has extensive clinical experience in post-acute care, having worked in skilled nursing and home health settings for the last 13 years. Melissa is a subject matter expert in post-acute care reimbursement, denials and appeals, and documentation compliance.
 
Melissa currently serves as the Vice President of Clinical Quality and Compliance for Continuum Rehab Group where she provides clinical education, develops and implements clinical programming, and oversees CRG's denials and appeals department and compliance program. She has previously written and presented continuing education courses in the areas of documentation, dysphagia, and dementia for the Texas Speech-Language and Hearing Association, ASHA, and other online continuing education platforms.



Related Courses

Building Your Case for Medical Necessity: The Nuts and Bolts of Skilled Therapy Documentation
Presented by Melissa Collier, MS, CCC-SLP, CHC, CDP
Video
Course: #9839Level: Introductory1.5 Hour
This course provides participants with an understanding of documentation requirements in a post-acute setting, including Medicare regulations and guidelines. It identifies why speech therapy services are denied and ways to mitigate the denial of skilled services, and describes how to document medical necessity.

Gold-Standard Documentation Strategies: Medicare and PDPM SNF Documentation
Presented by Lorelei O'Hara, M.A., CCC-SLP
Video
Course: #9673Level: Intermediate1.5 Hour
Scrutiny is the name of the game in skilled nursing facility (SNF) clinical service delivery. This course discusses how to create bullet-proof documentation using appropriate language and coding for Medicare Part A and B claims, and how to support the interdisciplinary team with iron-clad support for patient-driven payment model (PDPM) payment components, including cognitive and mood assessment tools.

OASIS Process Measures: Following best practices
Presented by Roberto I. Friedman, MA, CCC-SLP, MSHA, COS-C
Video
Course: #8660Level: Intermediate1 Hour
This course will provide an explanation of the process measures found in the Outcome and Assessment Information Set (OASIS). It will address changes that will be implemented in the OASIS-D beginning in January 2019.

Behavioral Frameworks for Dementia Management
Presented by Mary Beth Mason, PhD, CCC-SLP, Robert W. Serianni, MS, CCC-SLP, FNAP
Video
Course: #9473Level: Intermediate1 Hour
This course will focus on cognitive-communication intervention strategies for various dementia presentations and will provide a review of evidence-based treatment. Behavioral frameworks along with their rationales will be introduced and applied across several dementia types and mild, moderate and severe levels of impairment.

Dysphagia in Neurodegenerative Disease
Presented by Debra M. Suiter, PhD, CCC-SLP, BCS-S
Video
Course: #9732Level: Intermediate1 Hour
Dysphagia is common in individuals with amyotrophic lateral sclerosis (ALS) and Parkinson’s disease. This course discusses the underlying pathophysiology and appropriate treatment programs for each disease, as well as use of alternate methods of nutrition/hydration.