Questions about Medicare Guidelines

IF I WORK IN A SKILLED NURSING FACILITY DO I NEED TO SEE
A PATIENT FIVE TIMES A WEEK?

Frequency and duration issues are based on the patient’s condition and environment. If you are told you have to see a patient five, six, or seven times a week, this is not accurate information. There are times when speech pathology services are the only skilled service a patient receives. In this case, the patient must be seen at least five times weekly to receive Medicare benefits (room and board, medications, etc). However, most patients are receiving skilled nursing services and possibly physical therapy and/or occupational therapy (services that also enable a patient to receive Medicare benefits) so it is rare that the speech pathologist would have to see a patient five times each week. There are patients who do need to be treated five, six, or seven times a week because of their condition (severe dysphagia, severe aphasia, dysarthria). The decision to see a patient five or six times per week in a skilled nursing facility can be an appropriate option, but remember that it is the patient’s condition and the circumstances in the patient’s environment that determine frequency issues.

CAN I ONLY DO EVALUATIONS ON PATIENTS OR DO I HAVE TO ALWAYS PROVIDE AT LEAST ONE OR TWO TREATMENTS AFTER THE EVALUATIONS?

Evaluations only is an acceptable practice. There are times when your services are needed to provide specific information to help a physician accurately assess and manage a patient. Your services may be needed to determine if a patient has aphasia or dysphagia, or whether a patient is a candidate for an augmentative communication device or for non-oral feeding management. There are also times when your evaluation indicates normal voice, speech, language, and swallowing skills and when treatments are not indicated. These are all appropriate and reimbursable services. Some clinicians have reported being denied evaluations only because no recommendations or suggestions to help a patient maintain functional speech, voice, language, or swallowing skills were provided. Because of this, it may be a good idea, especially if you work in home health or an outpatient setting, to provide brief training to help a patient maintain specific skills related to speech, voice, language, or swallowing when you do not recommend treatment.

WHY WILL AN INTERMEDIARY IN ONE PART OF THE COUNTRY/STATE PAY FOR A SERVICE WHEN AN INTERMEDIARY IN ANOTHER PART OF THE COUNTRY/STATE WILL DENY THE SAME SERVICE?

Sometimes an intermediary misinterprets the guidelines. When this happens you need to activate the appeals process. Sometimes the guidelines are not well defined so intermediaries have the liberty to set their own policy in that area. One example where service guidelines are not well defined is in the area of dysphagia. The federal government still has not issued standards for diagnostic activities that must precede treatment. Because of this, some intermediaries have decided to require a modified barium swallow x-ray before any patient is seen for treatment. Other intermediaries have decided to require an x-ray study only when a pharyngeal stage dysphagia is suspected. There are even some intermediaries that may not allow an x-ray study or repeat x-rays studies. In situations where your intermediary has established their own guidelines, you will need to contact them to explain the specific needs of your patient and to negotiate services.

CAN THE WORD “CUEING” BE USED IN DOCUMENTATION?

Some clinicians have reported denials because the word cueing was used. Others say they are encouraged to use this word. Some reviewers may associate this word with drill work and may deny on this basis. You might consider eliminating this word and substituting the words “training and instruction”. My recommendation is that if you use this word, describe what you were doing with the patient. For example: Cueing provided to help patient locate appropriate tongue position to produce “L” sound in the word leg; redirected patient as necessary and trained in tongue elevation technique.

SHOULD I DISCHARGE A PATIENT WHO BECOMES ILL DURING A TREATMENT PERIOD?

If it is anticipated that the illness will be only a few days (patient may have the flu or be sick because a new medication is tried), you can document these reasons and put the patient on “hold” for several days. However, if it is anticipated that the illness will last several weeks, discharge the patient and re-evaluate when there is a change in condition that suggests the patient can now benefit from your service.

CAN A PATIENT WILL APHASIA AND DYSPAGIA BE SEEN TWO TIMES A DAY?

This is an acceptable and common practice. You do an evaluation for each disorder and separate progress notes (daily and monthly) for each disorder. You can use two separate forms for the evaluation and monthly progress notes or you can combine your services on one form. What is important is that your documentation reflects two separate disorders.

CAN I TREAT A PATIENT WITH A DIAGNOSIS OF DEMENTIA?

Medicare cannot deny your services just because you see a patient with dementia. Medicare can, however, deny your services because there is no expectation for progress. Medicare reviewers know that dementia is a progressive disorder that affects cognitive skills (reasoning, memory, judgment, generalization, attention, and/or problem solving). Reviewers know that without these abilities a patient is unlikely to demonstrate the ability to make progress. So when you decide to evaluate or treat a patient with dementia, be prepared to document positive expectation for progress. Perhaps the patient has mild dementia with enough cognitive ability to follow directions and attend to therapy tasks. Also, memory abilities may be adequate for carry over. It is critical that your documentation address these issues, especially if you are engaged in active (restorative) therapy.

Another option you have is to design and establish a functional maintenance program. When you choose this option, you are telling the reviewer that the patient would not benefit from active therapy because of poor cognitive abilities. You are also saying by training and instructing patient and caregiver, specific speech, voice, language, and/or swallowing skills can improve. Many patients with dementia demonstrate intact reading skills that can be sued to help the patient compensate for specific cognitive deficits. Many speech-language pathologists are designing memory books and memory wallets with success because many patients with dementia can comprehend printed material. Just remember that your goals must be related to speech, voice, language, and/or swallowing since these are the areas recognized by Medicare as being within the speech-language pathologist’s scope of practice.

Questions About the Minority Student Leadership Program

WHAT IS THE MINORITY STUDENT LEADERSHIP PROGRAM?

The Minority Student Leadership Program (MSLP) is a leadership development program established for undergraduate seniors, Master’s students, and/or AuD students who are enrolled in communication sciences and disorders programs and PhD students who are pursing a research doctoral degree.

WHAT IS THE PURPOSE OF THE MSLP?

• To recruit and retain racial/ethnic minorities which have been historically under-represented in the professions of Audiology and speech-language pathology.
• To provide focused educational programming and activities to build and enhance leadership skills.
• To provide and opportunity for program participants to interact with leaders in the professions of audiology, speech-language pathology, and speech, language, and hearing sciences.

WHO IS ELIGIBLE FOR THE MSLP?

Undergraduate seniors, Master’s and AuD students must be enrolled in communication sciences and disorders programs and are not members of ASHA

Preference will be given to students who are members of racial/ethnic minority groups historically under-represented within ASHA, including American Indian or Alaska native, Asian, Black or African American, Native Hawaiian, or other Pacific Islander, and/or Hispanic/Latino.

Graduate Study – the student must be enrolled in, or accepted for, graduate study in a communication sciences and disorders program in the United States. Master’s degree candidates and entry level clinical doctoral candidates must be in a program accredited by the Council of Academic Accreditation (CAA).

PhD Track – You must be enrolled in a research doctoral degree program. ASHA members may apply.

HOW ARE STUDENTS SELECTED FOR PARTICIPATION IN THE PROGRAM?

Forty (40) students are chosen to participate – 5 undergraduate seniors, 20 Master’s students, 5 entry level clinical doctoral students and up to 10 PhD students. MSLP applications are reviewed by a panel of ASHA members and rated on the following:

• Essay: use of description, strong argument/thesis, clarity, organization, and grammar and punctuation
• Resume: involvement in university/community activities and leadership experience
• Letter of support

Click here for the Minority Student Leadership Program applications.