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A Watched Pot Never Boils: Why Observing Swallowing is Unsuccessful and Risky

A Watched Pot Never Boils: Why Observing Swallowing is Unsuccessful and Risky
Katie Holterman, MS, CCC-SLP, BCS-S
February 10, 2020

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Editor’s Note: This text is a transcript of the course, A Watched Pot Never Boils: Why Observing Swallowing is Unsuccessful and Risky, presented by Katie Holterman, MS, CCC-SLP, BCS-S.

Learning Objectives

After this course, readers will be able to:

  • Describe differences between dysphagia screening, assessment and treatment, and elements that overlap between the three components.
  • Identify the Current Procedural Terminology (CPT) codes related to swallowing and explain how to decide which CPT codes to utilize.
  • Describe 2-3 principles of exercise science and neurorehabilitation principles as they apply to the treatment of dysphagia.

Introduction and Overview

I am really excited to present this topic because it is something I am very passionate about. I feel we, as clinicians, need to talk more about this topic; talk about what is actually going on in the field, how we are practicing, and how we can improve ourselves.

My financial disclosure is that I have received an honorarium from SpeechPathology.com for this course. For non-financial disclosures, I am a member of the American Speech and Hearing Association Healthcare Economics Committee and was an advisor for the American Medical Association CPT committee.

“A watched pot never boils.” We have all heard that expression, right? It refers to that feeling that time goes very slowly when you are anxiously waiting for something to happen. We all know watching that pot is useless. That is the figurative meaning. But there is a literal meaning to it - why just watching that pot is useless. There is science behind it. Without getting too geeky, the science of this is that the solubility of gases decreases when a temperature is raised, and that causes these air bubbles to go out from the water. The boiling point of water is reached at 212 degrees Fahrenheit, and then water vapor will form, and then you get these bubbles. It is not magic; it is science.

Why am I going over this? Because dysphagia and dysphagia treatment is about science. It is not just haphazard. I have to ask the question, what happens when you never turn on the stove? What happens if you do not apply any heat to the water? The pot of water is never going to boil. Similarly, we can say that if you do not actually perform any exercises for swallowing, the swallowing is not going to get better. The figurative example is really the same as the literal example, and it can be translated directly into our dysphagia treatment.

Skilled Therapy

The first thing we need to do is to define what skilled therapy is. Why am I going to a Medicare Benefit Policy Manual to do so? We all know Medicare is the “king of the therapy castle,” as it were. I would say a majority of our patients are Medicare beneficiaries. Of course, we do have patients who have other insurance types, but again, Medicare is the leader in that other third-party insurance companies will often follow along with what Medicare does. That is why we need to pull our definition of skilled therapy from Medicare and keep that at the forefront of our minds.

In order for a service to be considered skilled, it must have a benefit category, which speech pathology does, and the services must be reasonable and necessary. People often tell me, “That is so vague. What does that mean?” The Medicare Benefit Policy Manual spells that out for us as well.

Reasonable and Necessary

Chapter 15 of the Medicare manual states that in order to be reasonable and necessary, the services shall be considered “under accepted standards of medical practice to be a specific and effective treatment for the patient's condition.”

This is where acceptable practices for therapy services can be found: Medicare manuals, local coverage determinations (LCDs), and the guidelines and literature of the professions of physical therapy (PT), occupational therapy (OT), and speech. The guidelines and literature tell us what is evidence-based practice. So, in order for a therapy to be considered skilled, it has to be reasonable and necessary, and in order to be reasonable and necessary, it has to be backed by evidence-based practice.

Another part of the definition of reasonable and necessary is that “The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist.” We will not go into PT and OT, because we are talking about speech. Again, this discussion of “complexity and sophistication” is taken directly from the Medicare Benefit Policy Manual. The services are complex, and/or the condition is complex. Services that do not require the performance of a therapist are not skilled, so they are not considered reasonable and necessary, even if they are performed by a qualified professional. Just because you have “SLP” after your name does not make the treatment that you are doing skilled. The treatments performed have to be of a level of complexity and sophistication such that only an SLP who has gone to school, gained experience, and knows evidence-based practices can perform these types of exercises or therapy.

Another aspect of Medicare’s definition of reasonable and necessary is that Medicare coverage does not turn on the presence or absence of potential for improvement, “but rather on the beneficiary's need for skilled care.” The key issue is whether the skills of a therapist are needed, or whether the therapy or exercises can be carried out by non-skilled professionals. Remember, it is all based on whether the therapy that is being provided requires the skills of a therapist.

In addition, to be reasonable and necessary the amount, frequency, and duration of the services must be reasonable under accepted standards of practice; they must be reasonable for the condition present. If we are seeing a patient for dysphagia services, the amount, frequency, and duration need to be appropriate for that condition, which may be very different from what would be reasonable for some other condition and may vary from one person to another. But they must be reasonable.

Keep all of this in the back of your mind as we move forward because we are going to go back to the themes of “skilled therapy” and “reasonable and necessary” throughout the presentation today.

Dysphagia Screening, Evaluation, and Treatment

Now let's talk about the different components of what we can do related to dysphagia intervention. We have dysphagia screens, we have evaluations, and we have treatments. Under evaluations, we have clinical, or bedside, assessments, and we have instrumental assessments. We are going to delve into this going forward.

Screening, remember, is essentially a binary conclusion. It is either the presence or absence; a pass or fail. Is there something that indicates a condition is present or is there not? It is really the first step. It is something that you do to determine the need to go further and take a more comprehensive, deeper look.

Screening is very simplistic. Let’s move away from dysphagia and think about it in terms of other types of screenings for other medical conditions. When I was in the hospital and gave birth to my son, they gave me a postpartum depression screen. It was a question-and-answer type of survey to see if there was any indication that postpartum depression might be present. If I had those symptoms, I would then be referred for an evaluation. This is also similar to how a cardiac screen works. It is strictly to determine whether there is a need for additional evaluation. It is very simplistic and just a first step.

The evaluation or assessment, on the other hand, is more complex. The purpose of that evaluation is to identify and describe any atypical parameters of structures and functions, the effects of swallowing impairment on activities and how it impacts the patient on a day-to-day basis, and any other factors that serve as barriers. It looks more in-depth into what is occurring.

Evaluation/assessment may or may not lead to treatment. You may do an evaluation and say, “There is nothing more that I need to do.” This is similar to the situation with medical procedures, where you go in and have a full examination, and there is no indication for further services. Of course, on the other hand, you could have the need for treatment.

With dysphagia, you may have treatment that addresses restoration of normal swallow function, which is what we call rehabilitative treatment. You might instead work on modifications to diet consistency and patient behavior, which is a compensatory approach, or you might combine rehabilitative and compensatory approaches. All of this comes directly from ASHA's Practice Portal. If you have not gone to the Practice Portal on ASHA's website, it is a wealth of information, and I highly recommend it. It breaks down a variety of topics for dysphagia by discussing the research and what is needed for each of these components in an in-depth fashion.

Dysphagia Screening

Here are a few examples of dysphagia screenings:

  • Maxwell Swallow Screen
  • 3-ounce water swallow screen
  • Barnes-Jewish Hospital Stroke Dysphagia Screen (BJH-SDS) 

This is by no means a comprehensive list; there are a million out there. But these are some of the more popular ones. There are also dysphagia screenings that are not standardized. Certainly, there are many hospitals that have created their own. Remember, as long as it is giving some sort of indication of something that may need to be further investigated, that is considered to be a screening.

What is a dysphagia screening? What is involved and what are the components of a dysphagia screen? There is an interview that is usually fairly brief. There is observation for the presence of signs and symptoms of dysphagia. This observation most often occurs during routine or planned PO intake situations; in other words, observing a meal at bedside or something similar, in what, hopefully, is the patient's most natural environment. Administration of some standardized screenings, such as the 3-ounce water swallow screening, may also be included but sometimes it is simply an observation. The results must then be communicated to the healthcare team, along with a recommendation for additional assessment if needed. At its basis, it is simply an observation. Why are we doing this? We need to determine if the patient needs further assessment and/or intervention.

Dysphagia Evaluation

If we get into an evaluation, we take it one step further and it is definitely more comprehensive. I will go into the evaluation components in a little bit.

I always try to provide real-life examples, so here is one from my experience. About a year ago, I was having some pain in my shoulder but I just lived with it for a while. Finally, I said, “I cannot take this anymore,” and went to my doctor. He said, "This could be something," and did a pretty thorough examination of it. He then referred me to a physical therapist, who did an evaluation and worked together with the physician to come up with a diagnosis and a treatment plan. Remember that analogy. I think sometimes we get into our diagnostic mindset and we need to be reminded to make sure we are including the physician in this whole thing. I am going to pause on that story until we go further along and we will come back to it.  But that physical therapist did the evaluation and it was very thorough.

The elements of an evaluation include a fairly thorough review of medical history and a fairly thorough interview. In contrast with the screening, where you have a brief interview, you want to go in-depth with the evaluation. You will likely do an oral mechanism exam which might include a cranial nerve assessment, assessment of structure and function at various levels, and so on. You are going to take a look at overall cognitive-communication status because we all know that can have an impact on somebody's swallowing. You are going to look at speech and vocal quality.

Then you will likely be presenting boluses of various textures and looking for changes following those presentations. You monitor physiological status and look at secretion management. You are observing the patient, and this is highlighted on the slides for a reason. Let’s take a moment to discuss that.

Remember that we were observing the patient during the screening and now we are observing the patient in the evaluation. When we are doing observations, we are not trying to improve the swallow at this point. We are just watching the pot, observing the patient. Notice that we are still just talking about evaluation; all of this observation falls under the evaluation process.

A few other things you might assess are labial seal, anterior spillage, oral control, etc., as well as cough strength. I am not going to go into everything. Again, this is all in ASHA’s Practice Portal. In the end, of course, we want to make a judgment about whether we need to do an instrumental. There is a myth that the clinical dysphagia evaluation should never result in recommendations for specific therapy techniques. But that is not true. There are techniques that can be derived from a clinical assessment.

I want to pause here and go back to my PT story. If we think about the example of my shoulder, the PT did a clinical evaluation and came up with a plan of care. She did not rush me to an MRI or X-ray because there are some things that can be determined from a clinical evaluation. In contrast, a few years back, I broke my ankle. In that hospital ER, they needed to take an X-ray, but it was not just to find out if something was broken. It was to find out how it was broken; in other words, was it a displaced fracture or a non-displaced fracture? The treatment for those two types of fractures is very different. One requires a cast, and possibly surgery. One requires just a walking boot, or possibly a cast, but no surgery. That is the reason the X-ray was needed. Likewise, the instrumental swallowing exam is not simply to determine if there is aspiration or a certain type of swallowing dysfunction; its purpose is to determine the details. Going back to my shoulder, I did not need an MRI; a perfectly good treatment plan could be developed from the clinical evaluation.

In some instances, though, an instrumental evaluation is needed. When you have the need to further assess physiology, when the non-instrumental evaluation is completely inconsistent, when you need a differential diagnosis, or when there is a medical condition associated with a high risk of dysphagia, these are indications for performing an instrumental evaluation.  

Dysphagia Treatment

Rehabilitative vs compensatory. As I said, treatment can be rehabilitative, compensatory, or both. We think of rehabilitative treatment as more active; i.e., active exercises. Compensatory treatment can be either passive, for example, diet modifications, or passive/active. When changing diet consistency, we may be changing texture, temperature, viscosity, sensory feel, or size. We might also target patient behavior in a more passive/active-type way; this might include the use of compensatory strategies or positional techniques. We can have a combination of, and we probably should have a combination of, all of these.

Note that when I use the terms “passive” and “active,” I am not referring to what you do as the clinician. I am talking about patient actions. Modifying a diet consistency is considered “passive” because the patient is not doing anything; rather, you as the clinician are doing something. Just because the patient did not have to do anything, does not mean that you didn’t. But that is an important reason to document the skill needed in what you did. The documentation of skill is even more important in those passive types of treatment methods.

I love this statement from the ASHA Practice Portal: "Compensatory techniques alter the swallow when used but do not create lasting functional change. Rehabilitative techniques, such as exercises, are designed to create lasting change in an individual's swallowing over time by improving underlying physiological function." Let’s think about that. Do we want to create lasting change in function? I am pretty sure the answer would be a resounding yes for everyone.

Maneuvers. Let’s talk about the use of maneuvers as dysphagia techniques. Maneuvers are specific strategies that you can use to change the timing and/or the strength of swallowing during the swallow. Some of the more commonly used ones are the effortful swallow, the Mendelsohn maneuver, the supraglottic swallow, or the super-supraglottic. For the sake of this course, I am not going to go in-depth into each of these treatment techniques. Hopefully, you have an understanding of each of these prior to this webinar.

Exercises. There are oral-motor exercises, laryngeal elevation exercises, the Masako, and Shaker exercises. There are also lingual isometric or resistance exercises. So if we take the first three, these oral-motor exercises, that is really pretty broad, right. The term “oral-motor exercises” is broad, so be careful with the use of it. There are oral-motor exercises that have been proven to be non-beneficial. There are exercises that may be called “oral-motor exercises” or included in that grouping that are beneficial and have good research, but they are not truly oral-motor exercises.

The research findings related to laryngeal elevation exercises and the Masako are inconsistent with respect to benefits shown, so tread cautiously. The Shaker method has proven results; it has high-quality evidence from randomized controlled trials that it benefits swallowing.

If you use lingual isometric exercises or lingual resistance, you need to think about what is being targeted, and if that makes sense for your patient. Take the example of the Iowa Oral Performance Instrument (IOPI) versus a tongue depressor. If you are not familiar with the IOPI, it is a device used for lingual resistance. We have all had those instances where we use a tongue depressor. But my perception of a patient’s tongue strength as measured with a tongue depressor may be vastly different than yours or that of another person. There are no norms for that. There was actually a study, I believe by Heather Clark, that looked at inter-rater reliability of tongue pressure measurement using a tongue depressor, and the results were all over the place. The inter-rater reliability was poor. We really need to have objective measurements for these types of exercises. But if you use an IOPI or similar device, you can have objective measurements and active exercises using those can really make a difference in swallow rehabilitation.

Principles of exercise science: neuroplasticity. Let’s look at the principles of exercise science, and more specifically, neuroplasticity. There is a great article by Robbins et al. (2008), "Swallowing and Dysphagia Rehab: Translating Principles of Neural Plasticity into Clinically Oriented Evidence," that deals with these topics. We are going to go into some of these concepts and think about how we can tie them into our everyday treatment. There are various elements or principles related to neuroplasticity.

Use it or lose it. The first principle is use it or lose it. If you do not use a muscle, you are going to decondition that muscle. Take the example of learning a foreign language; this is a way of thinking about it that makes sense to me. I took French for six years through college. I was really good at it at the time, but then I did not use it for some time, and so I lost it. I can say very few words now.

The same thing applies to our musculature. If we do not use it, then we lose the ability to use it as well. This is where deconditioning comes into play. If I have a patient and I make that patient NPO (nothing by mouth), how does that help him or her? When choosing exercises for a patient who is NPO, we want to make sure that they mimic actual swallowing physiology as much as possible. That way, we ensure that the patient is using the muscles in the way they were intended.

Use it and improve it. The next principle is use it and improve it. I have heard some excuses, for lack of a better word, for not working on swallowing. Some of those excuses are that the patient is too weak or tires too much. I have even heard, “We are just waiting for the patient to improve.” Waiting is certainly not going to work! Another reason might be that the patient is not alert. That one, I understand. It is hard to do swallowing treatment when a patient is not very alert. But just remember that swallowing begets swallowing. The patient will not be able to improve unless he uses his muscles.

Specificity. Remember that treatment also works best if the activity involves more than just rote practice, but it is actually specific to that activity. Here is a PT example. Say you were to go to a PT, and she said, “Let's just strengthen that muscle by doing leg extensions.” Actually, it is better to walk; that is the best way to help improve that muscle.

Specificity has to do with using the exact - or specific - function or muscle movements that are needed. It has a direct application to swallowing therapy because we need to make sure that we are training the motor units specific to the task of swallowing. Our exercises need to target the specific muscles and movements used. Take the example of lingual resistance. If you are telling a patient to stick out her tongue in hopes of getting an improved swallow then you are really not doing the patient justice. When you stick out your tongue, the greatest pressure is right behind the incisors, in the front. For swallowing, we need that strength to be in the back. So again, specifically, target what you need to be improving because randomly using muscles that are only somewhat related to swallowing is not going to help swallowing.

Transference. The concept of transference has to do with the fact that practicing one skill can result in improvement of a related skill. Think about this in relation to compensatory strategies. If you can generalize those to real-world activities, they are going to have a better effect on patient function. Telling a patient to do a compensatory strategy while he is taking spoonfuls of applesauce may work, and it may translate into improved function. However, think about trying to get as close as you can to the actual activity that you want. In other words, if the patient does not like applesauce, he will never want to translate that strategy to regular food that he does like. If the patient likes chocolate pudding, use chocolate pudding.

Intensity. I think that we should do a lot more research on this topic. That being said, Lori Burkhead Morgan has done wonderful work in the area of intensity and exercise science. When it comes to swallowing experts, Lori Burkhead Morgan and Jim Coyle are two that I follow closely. I find Lori's work to be amazing.

She has stressed the importance not only of looking at the proper dosage – such as how many sessions, and how long those sessions should be - but also looking at how hard we are working the patient. We need to work the patient to the point of fatigue instead of simply choosing some random number of reps or weights with no scientific basis at all.

Repetition. The idea of repetition is an unknown but very important principle. We do not know how many sessions are ideal because we have not had enough research on this topic. Insurance payors want to know though. They want to know exactly how long it is going to take to make the patient better. Logically, the more intense the treatment is, then the better it is going to be, and the faster the patient should improve. We know that the ideal number is not going to be just one or two sessions. It might be 10 or 20, or it might not be. But we know from research in other areas that a high number of repetitions of certain activities are needed to generate changes. That would lead us to believe that the same principle would be true in dysphagia treatment.

Principles related to personal trainers.  I would get calls from nursing saying, "We would like you to reevaluate the patient today because she is better." I would pick up my magic wand and walk over to the room and say, "I have my magic wand to make her better. In one day, if she is better in such-and-such an area, then surely her swallowing is going to be better too.” I did not actually do that, but there were many occasions when I really wanted to! Obviously, we do not have magic wands and we do not have magic eyes. Watching patients or reevaluating them over and over again is not going to make them better. We must actively participate in sessions with patients to create the change.

Let's think about this from a personal training perspective.  Working with a personal trainer is a lot of work. I have had personal trainers before. Early on, one of them would say, "I am going to watch you run a mile and I am going to time you." Then he would yell, "Faster, faster, faster!" That did nothing but annoy me, and I did not really get that much faster. I may have gotten a little faster, but it certainly was not up to the speed where I wanted it to be. But I had another trainer who would say, "I am going to run a mile with you." He would stand next to me, and correct my posture, and cue my breathing. He would lift weights with me, too. And I got great results. He was active, and he made me active, and he gave me ideas that I actually could use moving forward. We want to make sure that we are being the best trainers we can be going forward.

CPT Codes

We are going to switch gears now and talk about CPT codes. We will eventually tie this all together, I promise, but first, let’s just do a quick run-through of the CPT codes that we use for swallowing.

  • 92610 – evaluation of oral & pharyngeal swallowing function (Clinical/non-instrumental)
  • 92611 - Motion Fluoroscopic evaluation of swallowing function by cine or video recording (MBS)
  • 92613, 92614, 92615, 92616, 92617 – Flexible fiberoptic endoscopic evaluation of swallowing (FEES)
  • 92526 - Treatment of swallowing dysfunction and/or oral function for feeding

The code for non-instrumental evaluation of oral and pharyngeal swallowing function is 92610. We have 92611 for the modified barium swallow (MBS), also known as a videofluoroscopic swallowing study. Codes 92613 through 92617 are for fiberoptic endoscopic evaluation of swallowing (FEES). Treatment falls under code 92526. All of these codes are service codes, meaning that they are untimed.

I have not listed the physical medicine codes, which are timed codes, and that is for a reason. A few insurance companies will allow those codes to be used. However, I would advise against that, for this reason. The dysphagia therapy code, 92526, is for the “treatment of swallowing dysfunction and oral function for feeding,” so it really covers everything. When you use a physical rehabilitation code, such as 97112 (neuromuscular re-education) or 97530 (therapeutic activity), you are actually listing the components that comprise 92526. Meaning, you are breaking down that 92526 service code into its constituent parts. You are being very duplicative in what you are stating, and from the perspective of coding, you are actually not being correct in how you are coding. The 92526 code covers all of what you have done but if you try to break it down and code 92526 along with the physical medicine rehab codes, you are being redundant. You don’t want to do that.

Again, all of our dysphagia codes are “untimed.” Does this mean you get unlimited time? Does it mean that you do not have to do any time, or do very little, and can still charge the code? No, there are still guidelines in place; there is actually an amount of time built into all “untimed” codes. Long ago, when I used to teach coding, I used to say that if it is an untimed code, you can see the patient for three minutes or 30 minutes or 300 minutes; it does not matter. I slowly started to realize that people were taking me literally. They would see a patient for two or three minutes and think they could charge for that. That is not true. It is not okay to see a patient for three minutes and say, “I did dysphagia therapy,” just because it is an untimed code.

You cannot charge the patient for simply sitting at the dining room table with her and saying, “Let me check how you are doing your swallowing. Oh, you are doing really well. You are using the compensatory strategy that I taught you. But wait, you should slow down a little bit. Okay, now your pacing is good.” It sounds crazy, but I hate to say that I have seen people do that. That is not a proper use of your service code. There is no skill involved in that. You are misrepresenting the amount of time built into that code, and you are misrepresenting what you have been doing. So, be careful about that.

92526 – Treatment of Swallowing Dysfunction

Let’s go back and take a look at 92526, which is for the treatment of swallowing function. Here are some things that actually should fall under evaluation, that I have seen listed in treatment notes:

  • Assessment of speech and vocal quality at baseline and any changes following bolus presentations
  • Presentation of various textures and assessment of effects of bolus delivery and/or compensatory strategy use  
  • *****Observation of the patient eating or being fed food items with consistencies typically eaten by the patient in a natural/typical environment for the patient's situation*****
  • Identification of signs and symptoms of penetration and/or aspiration, such as throat clearing or coughing before/during/after the swallow

How many times have you written or seen a treatment note that said, “Patient observed to eat five ounces of puree; no cough noted,” and that was documented as a treatment session? We are going to change that today. The items above are all evaluation components. Doing any of these activities is really an assessment; it is not treatment of swallowing. Charging 92526 for those activities is not correct because you are not treating the swallow.


Remember that our codes are universal. The 92526 treatment code and 92610 evaluation of swallowing code do not differ based on our setting. Just because you work in a skilled nursing facility (SNF) does not mean you use a different CPT code than someone who works in acute care or outpatient.

Now, there are differences in the way that we would bill based on the setting that we are in. Let’s go into that a little bit.

Acute care. For acute care, you bill under the Medicare Part A benefit by what is called a diagnosis-related group (DRG). Again, I am using Medicare as an example, though I understand that we have patients with other types of insurance.

The screening in acute care is usually done by nursing. We have easy access to do an instrumental evaluation because the instrumentation is right there. There are limits on the patient’s time and availability because patients are being brought in and out of their rooms for a million different tests and procedures. There is also the matter of patient complexity - patients are usually very sick in acute care. All of these factors can impact an evaluation.

Because patients are so sick and so complex, we end up doing reassessments fairly often. Personally, I think that is okay; that is simply what we need to do for those patients. But we have to be careful that we are not evaluating them one day, and then billing follow-up assessments as treatment. Re-evaluations are not treatment. If you are following up on patients to reassess them, you are not treating them. Be clear in what you are doing.

How often are we bringing patients down to our department versus seeing them at bedside? By that I mean, can we really do what we need to do to rehabilitate the swallow at the bedside when there are alarms going off and doctors in and out? If you have the ability, it would behoove you to actually bring the patient down to the department (if you have one) to work on the aspects of swallowing that you need to work on and utilize those principles of neuroplasticity.

Again, these patients are early on in their stage of illness. Sometimes it may just be that a reassessment is what is needed.

Skilled nursing. Right now, for skilled nursing, we are using the resource utilization group (RUG) IV system for payment. We are moving to the patient-driven payment model (PDPM). Hopefully, you have heard about that.

Again, we have screening in skilled nursing - generally a very hands-off type of observation - and we have an evaluation. Sometimes there is a set time allotted to you in your facility’s scheduling for evaluation, but there really should not be. You should use the amount of time that you need to use for an evaluation. In addition, there is the issue of resources. In a SNF, you do not have all the resources that you might have in an acute care setting, such as access to equipment for an instrumental evaluation.

In the current system of payment for treatment, you have a number of minutes that you are expected to see a patient. Again, you need to be doing what is clinically appropriate for the patient and not some number of minutes that have been set for you. You should be setting those minutes. At any rate, there will be a certain number of minutes allotted for that patient and you have to make sure you are using that time effectively for that patient, as well as making sure that the treatment is scaled to maximize the benefit in that number of minutes.

Other considerations for treatment in SNFs include, do you have the objective measurements and tools that you need in order to provide the best care for that patient? In SNFs, relative to acute care, you do have the advantage of having a more home-like environment in a dining room. But be careful with that home-like environment because it may be easy to slip into that habit of sitting back and watching somebody eat in that dining room. It is easy to think, “I can see four or five patients in a row because they are all sitting here. They have all come to me.” Instead, you have to make sure that you are actually doing something with the patient(s); something that is skilled and that is going to represent the code that you are using.

Outpatient. The situation is similar with outpatients. They have insurance and/or they have Medicare B. The screening would probably be part of an evaluation and the evaluation may consist of either clinical/non-instrumental or instrumental components or both. It depends on how your outpatient department is set up.

As for treatment, the patient’s condition has generally improved through the acute care stage and the skilled nursing stage, and perhaps the home-health stage as well. When you see someone in an outpatient setting, you often have a clean slate in front of you, in that you can do more – and more types - of treatment because the patient is less acutely ill at this stage. If you are doing more treatment, there may be a greater need for resources and tools.

All of this being said, whether you are in an outpatient setting, acute care, or skilled nursing, you cannot just sit back and only do compensatory strategies because you don’t have the resources or tools, or because the patients are a little more complex. If you are just working on compensatory strategies you are not putting in all the skilled treatment work that you could do, especially if you are doing the same strategies over and over again. We are going to go into some examples of that next.

When risk meets practice, you have to make sure that you are performing treatments that accurately represent the code that you are billing. You have to make sure that you are performing skilled therapy that is reasonable and necessary.

Case Examples

I want to look at some case examples. These are actual examples that I pulled from different patient charts. We will go through and discuss what was done, if it was clearly represented, and involved actual skill. Was something actually done for this patient that would be considered skilled or would it be considered something that a non-skilled healthcare provider could have completed? Would it be considered treatment at all or is it something that would be considered assessment instead of treatment? Just so you know ahead of time, none of these examples are skilled therapy.

Case Example 1

This was what was originally written, for a second visit with a patient:

  • Patient was seen bedside with spouse present.  Trials of thin liquid provided.  Patient observed to cough with thin liquids x6/10.  With verbal cues to utilize chin tuck patient tolerated thin liquids without cough on 9/10 trials.  Education provided to patient and wife regarding continuous use of chin tuck strategy. 

At first glance, perhaps you could say that is a nice objective measurement; it says how many trials and so on. But what does that really mean?

I am going to pause here. Let's just talk about the “t word” – tolerated. I tolerate peppers. I do not love them; I tolerate them. I tolerate my husband leaving his dirty socks all over the place, because I love him. “Tolerating” is a subjective term. In your documentation, do not use the word “tolerated.” It does not indicate that there is any skill in what you have done. It does not say anything about what the patient has done. When you look at that word in a sentence, what it really says is, “I sat back and watched and did nothing. There was nothing to do or I didn’t know how to do it.” It is subjective, so stay away from it.

This patient was status post-stroke. There was no instrumental evaluation provided. There was a follow-up with the patient and wife the next day after this specific example was written. The patient and the wife were unable to recall that education. In the line that states, "Education provided to patient and wife regarding continuous use of chin-tuck strategy,” that does not say what specific education was provided, nor how that was skilled. Could somebody else, like a doctor or patient care assistant, have provided that education? What was skilled about the education provided? What was the response to the education? Did the patient and the wife verbalize understanding? Were they able to return demonstrate what they learned?

Furthermore, there was an unclear rationale for use of the chin tuck. If you are going to use a strategy, do not just say that you are using a strategy. Again, that looks like you are just sitting around and watching the patient use a strategy. It does not take skill to say, “Hey, tuck your chin. Remember to tuck your chin. Did you tuck your chin?” That is not skill. If you can present a rationale for a chin tuck or whatever compensatory strategy you are using, then you are beginning to demonstrate some skill. Even more, skill can be demonstrated if you not only provide the rationale but also how you took that rationale and implemented it. Of note, the instrumental that was completed with this patient three days later demonstrated increased silent aspiration of thins when chin tuck was used. Be careful with the chin tuck if you are not assessing that under videofluoroscopy.

Case Example 2

Here is example two:

  • Patient seen during lunch.  Patient noted to have good intake of chicken, yogurt and thin liquids.  No overt s/s of aspiration noted. Patient with good rate of intake.  Recommend continue with current diet.  Discharge from speech therapy services.

“Good” and “adequate” are just like “tolerate.” Those terms are all very subjective and you should stay away from them. Their use leads to a risk of sounding like you don’t know really what to write and you did not really do anything skilled. The phrase, “good intake” could be taken as a dietary-related comment. A registered dietician can come in and say, “The patient had good intake of chicken, yogurt, and thin liquids.” A patient care assistant can say the same thing after going in to pick up the tray. That is not skilled. In addition, the last several comments look mainly like an assessment to me.

Here is the background on this example. The patient was actually evaluated on 12/15, and then the MBS was completed on 12/24. I am not really sure what happened between 12/15 and 12/24, why the patient was not seen on any other occasion, or why the MBS was recommended. There was no reason stated in the chart. There was a recommendation for regular solids and thin liquids on 12/24. There was impaired timing of vocal cord closure and bolus penetration to the level of the cords on 50% of the trials, but the penetrated materials were effectively cleared. The patient was then seen for five more follow-up treatment sessions which were billed 92526 each time on 12/26, 12/28, 12/29, 12/30, and 1/1.

Remember, reasonable and necessary means reasonable and necessary in frequency and duration. The patient was recommended for thin liquids and regular solids and was seen five times after that, and the notes for each of those follow-up sessions read very similarly to this one. It was as repetitive as you could get, as if it were copied and pasted each time. “Patient seen during mealtime. Patient with good intake on prescribed diet. Minimal throat clear. Patient appears to have fast rate of intake. No signs and symptoms of aspiration.” Non-skilled treatment involves routine, repetitive and reinforcing procedures. That is the definition of non-skilled. This could not be a clearer example of that. How many times have we seen this or maybe done it? We must make sure that we are getting away from this practice. What did we do with the patient? How was it skilled? How did we improve the swallowing?

Case Example 3

Let’s look at this one:

  • Patient seen with breakfast tray present.  Oral motor examination completed.  Labial and lingual strength appear WFL.  PO trials provided puree, mechanical soft, nectar thick and thin liquids. Patient with reduced mastication of soft solids.  Adequate bolus prep for puree.  Throat clear noted after thin liquid trials by straw.  No evidence of difficulty with nectar thick liquids.  Recommend downgrade to nectar thick liquids. 

This one includes our “A word,” adequate bolus prep. This description, and the recommendation of a diet downgrade, sounds more like evaluation than treatment.

It is basically a reassessment of the patient; yet, the clinician charged 92526. In addition, this note only says what the patient did and nothing about what the clinician did other than observing the patient. I see no skill demonstrated in this note. Unfortunately, this note is something that was actually written in the medical record.

Case Example 4

Here is our final example:

  • Oral motor exercises provided - patient with adequate lingual protrusion and resistance to tongue depressor improved from previous session.  Base of tongue exercises provided with verbal cues required for accuracy.  Patient utilized effortful swallow and double swallow during meals correctly 93% of the time as measured by palpation.

I am not going to read the whole thing, but let's break this down a bit. “Oral-motor exercises provided” does indicate there is something that the clinician did, it was active and went beyond just watching the patient. But you need to talk about your rationale as to why the exercises were done. As for the statement, “Adequate lingual protrusion and resistance to tongue depressor improved from previous session,” how do we know that? You did “base-of-tongue exercises,” but which ones? What does “provided” mean? Did you teach the patient how to do those, and/or did you provide written instructions? If you are simply providing written instructions and saying, “Okay, do this,” that is as risky as sitting back and watching the patient eat. Also, how are you testing the accuracy? And is palpation an adequate measurement for the effortful swallow?

In this example, the clinician was trying harder and was a little bit closer to the mark. But we still need to make sure we are documenting skill.


The bottom line is that we want to make sure that our services are clearly at a level of complexity and sophistication and that they are reasonable and necessary. Each time you see a patient and each time you are writing your note, think of your skill. Think of what you want the patient to be doing and how to move the patient in the right direction to improve the swallow. Make sure that you are not just sitting and observing then charging a code for treatment.

Questions and Answers

Is the 3-ounce water swallow screening the same as the Yale?

Yes, I use the terms interchangeably.

Can you please clarify the time component of service-based CPT codes? I am not clear on what you were saying about minimum or maximum sum of time.

A timed code usually is a 15-minute code, though there are timed codes that are 60 minutes long or other durations. The timed codes are pretty self-explanatory; they have a time directly associated with them. Service codes are “untimed” meaning you can see the patient for an unlimited amount of time; however, there is still a built-in time for each code. I do not have the exact built-in time for each of those service codes. But there is a time built in and you can go to your CPT manual to look for that. I believe it is available online. The point of that statement is really to emphasize that you cannot see the patient for three minutes and then say, “Okay, I am done.” That would not be adequate. Just because it is service-based and not “timed” does not mean it is a free-for-all. The point of that slide was really to make everybody aware that “service-based” or “non-timed” does not mean there is no time associated with them at all.

What is a non-swallowing exercise that has high-quality evidence? Did you say the Shaker does have good evidence?

That is correct. The Shaker does have good evidence behind it and is one of the non-swallowing exercises that has the highest reliability.

With regard to nursing screens, in my facility, the nurses are actually documented as doing evals. They overstep boundaries and often jump in to evaluate the patient before we get downstairs to complete it ourselves. Legally, we have 24 hours to respond and we always respond within the same day. But what is our purpose, if RNs are taking overfeeding and completing swallowing evaluations?

First of all, our purpose is to make sure that we are advocating for our profession. I am not taking anything away from nurses; some of my best friends are nurses and I have worked with excellent nurses. But the nurses that are my friends will be the first ones to say, "We do not know everything about swallowing, and we certainly do not know as much as speech pathologists." Yes, unfortunately, this situation is common. Part of the issue is the order set that is built into these electronic systems. There is an order set that says “Screen,” and then it says “Evaluate,” or the documentation language says “Evaluation completed” when it was supposed to be a screening. So, part of this is just a byproduct of those documentation order sets. But we have to advocate for our profession. We are highly skilled, trained professionals. We have expertise. Some of us have board certification in swallowing. It is something that we need to take pride in and take the opportunity to educate by saying, “This is what we know. This is what we can provide to the patient.” More importantly, this is why it is very important for us to not just go in, watch the patient, and document that we provided a therapy session. This is where we really need to be seen as providing therapy, if that makes sense.

Say you have a patient who has been on a particular diet, such as puree, and you want to see if it can be upgraded. Is that going to be a reassessment? How do you see if it is time for them to be upgraded? Then once you upgrade them, how do you make sure they are not exhibiting any signs and symptoms of difficulties with that new diet?

I think this is a conundrum and we run into this situation frequently where we feel like we have to constantly upgrade our patients. That comes from a good place; nobody wants to be on puree and honey-thick liquids. We want to try to get them off those types of diets as soon as possible. But if you are reassessing the patient, you are reassessing the patient. You need to make sure you are stating that it is a reassessment and not a treatment. There is a component of “diagnostic treatment” that falls into what we do. But I feel like we, as a field, get into this habit of constantly assessing. If that is all you are doing during the session, you are not doing treatment. Yes, there is a point where you are going to need to reassess your patient; I think that is valid. But again, go back to the definition of “skilled” and “reasonable and necessary.” What is the frequency and duration? If you are reassessing every day, or even once a week, that is probably not reasonable and necessary. You need to give that patient time to rehabilitate the swallow. Think about how often you are doing this, and if it is realistic. If you are reassessing at an interval that is reasonable and necessary, then the reassessment is expected and would be considered skilled at that time.


Holterman, K. (2020). A Watched Pot Never Boils: Why Observing Swallowing is Unsuccessful and Risky. SpeechPathology.com, Article 20339. Retrieved from www.speechpathology.com

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katie holterman

Katie Holterman, MS, CCC-SLP, BCS-S

Katie Holterman, MS, CCC-SLP, BCS-S, is Director of Clinical Education/Compliance for EnduraCare Acute Care Services. She is board certified in swallowing disorders and is a certified dementia care instructor through Dementia Care Specialists.  She serves as a member of the Professional Development Committee for ASHA’s SIG 13, is a member of ASHA’s Healthcare Economics Committee (HCEC), and served as an advisor to American Medical Association’s CPT Health Care Professionals Advisory Committee (HCPAC).  Having nearly 20 years of clinical experience, Ms. Holterman has both provided clinical care, and held leadership roles, in a variety of clinical care settings including acute care, hospital outpatient, subacute rehab, long term care, and private practice.  Ms. Holterman has presented nationally on topics including dysphagia, health literacy and professional issues in rehabilitation.

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