Dcumentatin f Skilled Versus Unskilled Care fr Medicare Beneficiaries Medicare guidelines state that all services must be medically necessary and be prvided at a level f cmplexity and sphisticatin that requires a speech language pathlgist t perfrm the tasks. They further stipulate that the interventins prvided require the expertise, knwledge, clinical judgment, decisin making and abilities f a therapist that assistants, qualified persnnel, caretakers r the patient cannt prvide independently (Medicare Benefit Plicy Manual, Chapter 15, Sectin 220.3B www.cms.gv/regulatins and Guidance/Guidance/Manuals/dwnlads/bp102c15.pdf). What are examples f skilled services? Speech language pathlgists use their expert knwledge and clinical decisin making t perfrm the skilled services listed belw. Analyze medical/behaviral data and select apprpriate evaluatin tls/prtcls t determine cmmunicatin/swallwing diagnsis and prgnsis. Design plan f care (POC) including length f treatment; establishment f lng and shrt term measurable, functinal gals; and discharge criteria. Develp and deliver treatment activities that fllw a hierarchy f cmplexity t achieve the target skills fr a functinal gal. Based n expert bservatin, mdify activities during treatment sessins t maintain patient mtivatin and facilitate success. Increase r decrease cmplexity f treatment task. Increase r decrease amunt r type f cuing needed. Increase r decrease criteria fr successful perfrmance (accuracy, number f repetitins, respnse latency, etc.). Intrduce new tasks t evaluate patient s ability t generalize skill. Engage patients in practicing behavirs while explaining the ratinale and expected results and/r prviding reinfrcement t help establish a new behavir r strengthen an emerging r incnsistently perfrmed ne. Cnduct nging assessment f patient respnse in rder t mdify interventin based n: patient perfrmance in treatment activities; patient reprt f functinal limitatins and/r prgress. Ensure patient/caregiver participatin and understanding f diagnsis, treatment plan, strategies, precautins, and activities thrugh verbalizatin and/r return demnstratin. Train and prvide feedback t patients/caregivers in use f cmpensatry skills and strategies (e.g., feeding and swallwing strategies, cgnitive strategies fr memry and executive functin). Train caregivers t facilitate carry ver and generalizatin f skills. Develp, prgram, and mdify augmentative and alternative cmmunicatin system (lw tech r high tech). Instruct patient and caregiver in use and care f cmmunicatin system. Develp maintenance prgram t be carried ut by patient and caregiver t ensure ptimal perfrmance f trained skills and/r t generalize use f skills. Fr patients with chrnic r degenerative cnditins, evaluate patient s current functinal perfrmance; prvide treatment t ptimize current functinal ability, prevent deteriratin, and/r mdify maintenance prgram (Medicare Benefit Plicy Manual, Chapter 15, Sectin 220.2 C&D). 2200 RESEARCH BOULEVARD ROCKVILLE, MARYLAND 20850-3289 301-296-5700 VOICE OR TTY www.asha.rg
Examples f Infrmatin t Be Included In Dcumentatin f Skilled Services T dcument skilled services, the clinician applies the tips listed belw. Use terminlgy that reflects the clinician s technical knwledge. Indicate the ratinale (hw the service relates t functinal gal), type, and cmplexity f activity. T address wrd retrieval skills, patient named five items within a categry. A limit f 12 secnds made the activity mre cmplex than that tried in the last sessin. Because patient has residue in the muth with slids, putting him at risk t aspirate that material, he perfrmed tngue sweeps f the buccal cavity with minimal cues n 80% f slid bluses. Reprt bjective data shwing prgress tward gal, such as accuracy f task perfrmance (e.g., 50% accuracy in wrd retrieval in sentence cmpletin tasks); speed f respnse/respnse latency (e.g., patient demnstrated 7 10 secnds f delay fr auditry prcessing f sentence level infrmatin; delay reduced t 3 secnds with supplemental written cues); frequency/number f respnses r ccurrences (e.g., patient swallwed 6/10 PO trials f ½ tsp bluses f puree textures with n delay in swallw initiatin); number/type f cues (e.g., initial phneme cues prvided n half f the trials); level f independence in task cmpletin (e.g., patient verbally described all cmpensatry strategies t maximize swallw safety independently, but required minimal verbal cues frm SLP/caregiver t safely implement them at mealtimes); physilgical variatins in the activity (e.g., patient demnstrated increased fatigue characterized by increasingly lnger pauses between utterances). Specify feedback prvided t patient/caregiver abut perfrmance (e.g., SLP prvided feedback n the accuracy f cnsnant prductin; SLP prvided feedback t caregiver n hw t use gestures t facilitate a respnse). Explain decisin making that result in mdificatins t treatment activities r the POC. Explain hw mdificatins resulted in a functinal change (e.g., patient s attentin is enhanced by envirnmental cues and restructuring during mealtime, allwing her t cnsume at least 50% f meal withut redirectin). Explain advances based n functinal change (e.g., cughing has decreased t less than 2x/6 z. drink; liquids upgraded frm nectar t thin). Indicate additinal gals r activities (e.g., speech intelligibility remains impaired due t flexed neck and trunk psture and reduced vlume; gals fr diaphragmatic breathing will be added t POC t encurage imprved respiratry supprt fr verbal cmmunicatin and increased vlume f phnatin). Indicate drpped r reduced activities (e.g., cuing hierarchy was mdified t limit tactile cues t enable greater independence in patient s use f cmpensatry strategies at mealtimes). American Speech Language Hearing Assciatin Page 2
Indicate changes in target activities r respnse criteria (e.g., patient was able t identify target picture with 90% accuracy in field f fur; picture cmmunicatin chart [fur pictures/page] was intrduced t train patient fr functinal cmmunicatin f wants and needs; patient perseverating during naming task, s added a 5 secnd pause between stimuli and this imprved accuracy). Elabrate n patient/caregiver educatin r training (e.g., trained spuse t present twstep instructins in the hme and t prvide feedback t this clinician n patient s perfrmance). Evaluate patient s/caregiver s respnse t training (e.g., after demnstratin f cuing techniques, caregiver was able t use similar cuing techniques n the next five stimuli). What are unskilled services? Unskilled services d nt require the special knwledge and skills f a speech language pathlgist. Skilled services that are nt adequately dcumented may appear t be unskilled. Unskilled dcumentatin examples are listed belw. Reprt n perfrmance during activities withut describing mdificatin, feedback, r caregiver training that was prvided during the sessin (e.g., patient was 80% accurate n divergent task; patient tlerated diet [r treatment] well). Repeat the same activities as in previus sessins withut nting mdificatins r bservatins that wuld alter future sessins, length f treatment, r POC (e.g., cntinue per POC, as abve). Reprt n activity withut cnnecting the task t the lng r shrt term functinal gals (e.g., patient has treatment plan t address intelligibility related t dysarthria, but the nte simply states patient able t read a sentence and fill in the blank n 90% f trials ). Observe caregivers withut prviding educatin r feedback and/r withut mdifying plan. Treatment Ntes Mtr Speech Examples f Skilled and Unskilled Dcumentatin Gal: Imprve speech intelligibility f functinal phrases t 50% with minimal verbal cues frm listener. Unskilled treatment nte: Pt cntinues t present with unintelligible speech. Treatment included cnversatinal practice. Recmmend cntinue POC. Cmment: This treatment nte des nt prvide bjective details regarding patient s perfrmance. Skilled treatment nte: Pt cntinues t have unintelligible speech prductin; unable t cnsistently make needs knwn. Intelligibility at single wrd level: 60%; phrase level: 30%. Pt benefits frm SLP s verbal cues t reduce rate f speech and limit MLU t 1 2 wrds. Listener has better understanding if pt pints t 1st letter f wrd first. Pt demnstrated imprved selfawareness f intelligibility relative t last week s sessin. American Speech Language Hearing Assciatin Page 3
Aphasia Shrt term gal: Pt will prduce ne wrd respnses t functinal wh questins x 60% with min cues. Unskilled treatment nte: Pt prduced wrd level respnses with 70% accuracy in treatment sessin with verbal cues. Cmment: This nte des nt include mdificatin f the plan f care based n patient perfrmance and des nt detail skilled treatment activities. Skilled treatment nte: Wrd level respnses t wh questins t: self and ADLs: 70% accuracy Dementia semantically abstract questins: 50% accuracy Benefits frm phnlgical (initial syllable) cues but unable t self cue successfully. Naming nuns is better than verbs. Perfrmance imprves when pt attempts written respnse t augment verbal utput t facilitate phne grapheme assciatins. Shrt term gal: Pt will use cmpensatry strategies fr rientatin t time t reduce agitatin with 80% accuracy when cued by staff Unskilled treatment nte: Pt recalled events that ccurred earlier tday with 50% accuracy. Cmment: This treatment nte des nt supprt the shrt term gal in the plan f care. Skilled treatment nte: Spaced retrieval techniques were used t train pt t lcate calendar, check clck, and lk n whitebard fr daily schedule. Pt respnded t tempral rientatin questins relating t persnal histry (x 50% accuracy) and schedule at current living envirnment (x 60% accuracy) with md verbal cues prvided by SLP/caregiver. Pt benefitted frm verbal rehearsals t imprve independence in use f cmpensatry strategies. Vice Shrt term gal: Pt will cmmunicate in phrase level utterances x 10 with apprpriate vcal quality, pitch, and ludness t indicate wants/needs. Unskilled treatment nte: Pt tlerated speaking valve fr 30 minutes. Cmment: There is n clear cnnectin between the daily nte and the shrt term gal. Skilled treatment nte: Speaking valve was placed t help facilitate verbal cmmunicatin. Pt repeated 10phrases withut visible signs r symptms f respiratry distress fr 30 minutes. Pt s SPO2 level maintained 99% 100% during the entire sessin. Prgress Ntes Cgnitin/Executive Functin Shrt term Gal: Pt will use cmpensatry strategies t recrd upcming appintments with 90% accuracy. Unskilled prgress nte: Pt was given an appintment bk fr recrding upcming appintments. Cntinue established POC. American Speech Language Hearing Assciatin Page 4
Dysphagia Cmment: This nte des nt reprt the patient s perfrmance and prvides n descriptin f mdificatin r feedback. Skilled prgress nte: A 3 step prcess was prvided in writing t help Mrs. J g thrugh the steps f recrding appintments in her pcket calendar. She practiced with trial appintments until she replicated the 3 steps with 100% accuracy with minimal verbal cues. Shrt term gal: Pt will safely cnsume mechanical sft diet with thin liquids x 3 meals per day with 1 vert s/s f aspiratin t meet all nutritin/hydratin needs. Unskilled prgress nte: Pt has been tlerating mechanical sft/thin liquid diet well. Cmment: This prgress nte des nt reflect change in status as a result f skilled interventin. Skilled prgress nte: Pt has been seen fr 8 treatment sessins during this perid. Pt s diet was upgraded frm puree/nectar thick liquids t mechanical sft/thin liquid diet. Pt safely cnsumed 3 trial meals at lunch with n vert signs and symptms f aspiratin. Pt requires md verbal cues t safely implement cmpensatry strategies. The shrt term gal has been updated t include trials f regular texture fds. Plan f care includes caregiver educatin prir t discharge. Discharge Ntes Dysphagia Unskilled discharge nte: Pt has made prgress during treatment. Pt and wife educated n use f swallw strategies fr safety. Recmmend discharge SLP services at this time. Cmment: This nte des nt detail skilled interventin, patient s functinal change in status, r skilled aspects f caregiver training. Skilled discharge nte: Skilled SLP services included caregiver educatin, dysphagia management, therapeutic diet upgrade trials, cmpensatry strategies (pacing, full ral clearance, cyclic ingestin, relaxatin technique fr cntrlled breathing) and discharge cunseling. Pt currently has rders fr mechanical sft with thin liquids x 2 meals (breakfast/lunch) but remains n puree at dinner. Significantly reduced swallw safety nted in evening due t increased cgnitive behaviral changes assciated with sun dwning. Pt and his wife educated re: cmpensatry swallw strategies t imprve safe and efficient swallwing with 100% return demnstratin f strategies by his wife. SLP educated pt and family n the need t implement relaxatin strategies while eating due t pt experiencing anxiety during meal times. Recmmend pt returns hme with hme health SLP services t address swallw safety while maximizing efficient PO intake n mechanical sft diet with thin liquids. The interpretatin f Medicare guidelines and examples abve are cnsensus based and prvided as a resurce fr members f the American Speech Language Hearing Assciatin. Fr clinical and dcumentatin questins, cntact Healthservices@asha.rg. Fr Medicare and reimbursement questins, cntact reimbursement@asha.rg. American Speech Language Hearing Assciatin Page 5