ASC 823J: Medical Aspects of Speech Language Pathology Medicare, Medicaid Guidelines

Medicare/Medicaid Government health care for the elderly and/or government dependents Medicare services covered at a: –duration –intensity –severity of the impairment –beneficiary’s response All are concepts that are interrelated to the provision of service.

Misconceptions Duration and intensity –not "set in stone" by reviewers Patient diagnosis –Progressive neurologic diseases –Dementia Time post-onset –beyond the acute epoch Age –is not defined, should not be a factor given the other guidelines are met

The Glass is... Terminology issues –words/phrases used can impact the likelihood of payment –Sets the tone for expectation of progress, or necessity of skilled services Tx can be provided in the following areas –speech –language –swallowing –voice

Half empty... Poor cognitive skills Pt. not oriented to time or place Status unchanged Maintenance tx Monitored during mealtime Pt. Confused No significant difficulties noted Oral motor exercises were stressed

Half full... New skill acquired Designed and established a functional maintenance program Pt. ready for next step in tx Ability to generalize noted Higher level language skills noted Training and instruction Functional vocabulary increased Deficits require skilled tx

Treatment Goals Measurable Functional Pt. Related Focused on the areas reimbursed –at least 50% Long term goals –level attained Short term goals –steps taken

Example Training and instruction to help patient use "head down" compensatory strategy –Pt. Will demonstrate safe swallow of a 1/3 tsp pureed bolus using the "head down" with 90% effectiveness Training and instruction in specific oral muscle movement patterns to improve safety of the swallow –Pt. Will demonstrate functional lip closure to keep food in the oral cavity for 9/10 swallows (1/3 tsp. bolus)

Evaluations Questions reviewers will ask when viewing eval docs. –What happened: reviewers will look for medical diagnosis associated with a specific ICD code. –When –Premorbid skill level –Current presenting problems –Prognosis for improvement –Skilled tx required? –Recommendations include functional outcomes?

ICD Codes Primary Codes –CVA Tx Codes –Apraxia –Aphasia –Dysarthria –Agnosia –Dysphagia Tx codes must be in line with diagnostic codes, or it may be basis for denial of payment Codes would be on Tx plan

Premorbid Skills Premorbid abilities –previous CVAs –other neurologic events –normal functioning Cannot set goals higher than the prior level of function Current functioning –make sure to describe deficits so that reviewer can see that it is a covered aspect of speech/language and swallowing

Deficit statements Because of dysarthria the patient is unable to produce understandable speech to communicate wants and needs. Speech intelligibility is currently at the 20% level of effectiveness. The aphasia has produced a symbolic dysfunction that interferes with the patient’s ability to recall and use single words to communicate wants and needs. This ability is currently at the 30% level of effectiveness.

Deficit statements cont’ Although these are acceptable statements according to Medicare guidelines, a clinician should question them. What’s wrong with these statements? You must provide the basis for your observations Standardized tests –requires skilled administration Informal observation –requires skilled interpretations

Summary of Evaluation State the medical diagnosis Specify the date of occurrence or change in condition Describe the conditions the you are qualified to treat Explain why speech services are needed Specific training and instruction that needs to be conducted Functional levels of independence

Progress Notes Home health –progress report every 60 days All other settings –progress report every 30 days Functional goals Need for skilled services Progress related to functional goals Positive expectation for improvement if the patient is to be seen for another month

What are "skilled services"? Diagnostic/assessment Designing Tx plans Establishing compensatory skills Establishing hierarchical tasks and cueing that directs a pt. toward communication goals Analysis related to actual progress toward goals Patient and family training to augment tx or facilitate maintenance

Reimbursement for tx For services to be reimbursed by Medicare, the reviewer must feel that Pt skills were being constantly analyzed and the clinician was constantly providing feedback to facilitate positive change in behavior. Reviewers look for this in documentation

Progress Note Summary Functional goals addressed Knowledge and training of a professional is necessary Progress must be related to functional progress toward established goals Comparison statements must be included in the documentation Positive expectation for continued progress

Cautionary Note Although Medicare may only require monthly notes, if they have questions regarding tx sessions, they may want to review session notes. Keep session notes in the same format, remembering the wording etc. Medicare can deny payment of individual therapy sessions

700 and 701 forms Necessary for home care and some medical facility situations

Medicare Denial Criteria Services are not reasonable nor are they necessary Services are not considered skilled services