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MEETING THE MEDICARE MARK

ReneeKinderMSCCC‐SLPRAC‐CTIndianaSpeechLanguageHearingAssociationSaturdayApril16th 9:30‐11:30

COURSE DESCRIPTIONProvidinghighqualitydocumentationofskilledservicestoMedicarebeneficiariesbeginswithanadequateunderstandingofregulationssetforthviatheMedicareBenefitPolicyManualandLocalCoverageDeterminations(LCDs)inregardstokeyareasincluding:

skilledversusnon‐skilledprocedures;

traditionalinterventionsversusmaintenancebasedplansofcare

establishinginterventionstopromotereturnfrombaselinetopriorleveloffunction

initiatingcaregivertrainingtopromotecarryoverofskilledinterventionsupondischargefromcare

anddocumentingoutcomesofreasonableandnecessaryservicesviagoaltargetswhicharefunctionalandmeasureable.

OBJECTIVES:

1.Participantwillbeabletocreatefunctionalgoaltargetstopromotereimbursementofservicesandevidenceoutcomes.

2.Participantwillbeabletoidentifykeyareasfordocumentingreasonableandnecessaryservices.

3.Participantwillbeabletodescribeprocedureswhichsupportskilledcare.

CODING:YOUR FIRSTDEFENSE

CODING‐ KEEPING CONTROL

YOURSTCLAIM

EMRBOMPAYER

CPT:EvaluationCodes

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92610EVALUATION OF ORAL &PHARYNGEAL SWALLOWING FUNCTIONMedicareBenefitPolicyManual(MBPM),DysphagiaDefined:

Dysphagia,ordifficultyinswallowing,cancausefoodtoentertheairway,resultingincoughing,choking,pulmonaryproblems,aspirationorinadequatenutritionandhydrationwithresultantweightloss,failuretothrive,pneumoniaanddeath.Itismostoftenduetocomplexneurologicaland/orstructuralimpairmentsincludingheadandnecktrauma,cerebrovascularaccident,neuromusculardegenerativediseases,headandneckcancer,dementias,andencephalopathies.Forthesereasons,itisimportantthatonlyqualifiedprofessionalswithspecifictrainingandexperienceinthisdisorderprovideevaluationandtreatment(1).

MBPM,SwallowingAssessmentInclusions:

Swallowingassessmentandrehabilitationarehighlyspecializedservices.Theprofessionalrenderingcaremusthaveeducation,experienceanddemonstratedcompetencies.Competenciesincludebutarenotlimitedto:

Identifyingabnormalupperaerodigestive tractstructureandfunction

Conductinganoral,pharyngeal,laryngealandrespiratoryfunctionexaminationasitrelatestothefunctionalassessmentofswallowing

Recommendingmethodsoforalintakeandriskprecautions

Developingatreatmentplanemployingappropriatecompensationsandtherapytechniques(2).

NEW EVALUATION CODES 2014

BackgroundEffectiveJanuary1,2014,CurrentProceduralTerminology(CPT,©AmericanMedicalAssociation)forcode92506(Evaluationofspeech,language,voice,communication,and/orauditoryprocessing)willbedeletedandreplacedwithfournew,morespecificevaluationcodesrelatedtolanguage,speechsoundproduction,voiceandresonance,andfluencydisorders.

WHEN SHOULD ISTART USING THE NEW CODES?

YoushouldhavestartedusingthenewcodesforbillingpatientsonorafterJanuary1,2014.

WHY DID FOUR NEW CODES REPLACE CPT92506? ThefournewevaluationcodesweredevelopedbyASHA'sHealthCareEconomicsCommittee(HCEC) in

collaborationwithexpertsinthefieldfromASHA'sSpecialInterestGroups.

TheHCEChasbeenworkingwiththeAmericanMedicalAssociation(AMA)tochangemostspeech‐languagepathologycodessince2009,whenanewlawtookeffectthatallowsprivatepracticeSLPstobillMedicaredirectlyfortheirservices.Becauseofthatchange,theAMA'sRelativeValueUpdateCommitteere‐evaluatedspeech‐languagepathologycodestoinclude"professionalwork"value(oneofthreecomponentsofacode'svaluethatreflectstheamountoftime,technicalskill,physicaleffort,stress,andjudgmentrequiredtoprovidetheservice).Priorto2009,SLPswereconsidered"technicalsupport"andtheirworkwasincludedinthe"practiceexpense"componentofthecode'sreimbursementformula.Duringthisprocess,theRUCrecognizedthatCPT92506reflectedmorethanoneprocedure;thisrecognitiongaveASHAanopportunitytodevelopspecificevaluationprocedurecodestoreplace92506andmoreaccuratelyandappropriatelyvaluetheprofessionalworkperformed.

NEW CODES DEFINED

92521 Evaluationofspeechfluency(e.g.,stuttering,cluttering)

92522 Evaluationofspeechsoundproduction(e.g.,articulation,phonologicalprocess,apraxia,dysarthria)

92523 Evaluationofspeechsoundproduction(e.g.,articulation,phonologicalprocess,apraxia,dysarthria);withevaluationoflanguagecomprehensionandexpression(e.g.,receptiveandexpressivelanguage)

92524 Behavioralandqualitativeanalysisofvoiceandresonance

CAN NEW CODES BE BILLED TOGETHER SAME DAY?

TheCPTHandbook doesnotincludelanguagetorestrictanSLP'sabilitytobillthesecodestogetherbecausetherearecircumstanceswhenitisappropriateforapatienttobeevaluatedformultipledisordersonthesameday.

Note‐ Inthosecases,documentationshouldclearlyreflectacompleteanddistinctevaluationforeachdisorder.

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92521‐ EVALUATION OF SPEECH FLUENCY

Inclusions‐ EvaluationofStutteringandCluttering Thefollowingdisordersaretypicallynon‐coveredforthegeriatricMedicarebeneficiary: Fluencydisorder Dysprosody Stutteringandcluttering(exceptneurogenicstutteringcausedbyacquiredbraindamage)

92522‐EVALUATION OF SPEECH SOUNDPRODUCTION

Inclusions‐ Articulation,PhonologicalProcess,Apraxia,Dysarthria

92523EVAL OF SPEECH SOUND PRODUCTIONWITH EVAL OF

LANGUAGE COMPREHENSION AND EXPRESSION

Inclusions‐ Articulation,PhonologicalProcesses,Apraxia,Dysarthria;ReceptiveandExpressiveLanguage

92523IS COMBINED SPEECH SOUND PRODUCTION AND

LANGUAGE ?WHAT IF IONLY EVALUATE LANGUAGE?

Iftwoormoreproceduresarebilledtogetheratleast51%ofthetime,itisstandardtodevelopabundledCPTcodeforthatsetofservices.

ASHAsurveyedpracticesandclinicsandconfirmedthatevaluationsforlanguageareaccompaniedbyevaluationsforspeechsoundproduction80%ofthetime.However,thereverseisnottrue.Itiscommonforspeechsoundproductionabilitiestobeevaluatedindependentofalanguageevaluation,whichiswhythereisastand‐alonecodeforspeechsoundproductionevaluation.

Ifapatientisevaluatedonlyforlanguage,SLPsshouldbill92523withthe‐52modifier,whichisusedwhentheservicesprovided arereducedincomparisonwiththefulldescriptionoftheservice.

CAN IBILL 92522AND 92523SAME DAY?

No,youmayonlybilloneortheother.Aspeechsoundproductionevaluation(CPT92522)isalreadyincludedasapartofCPT92523(speechsoundproductionevaluationwithlanguageevaluation).

92524BEHAVIORAL &QUALITATIVE ANALYSIS OF VOICE &RESONANCE

Q‐ DoesCPT92524(behavioralandqualitativeanalysisofvoiceandresonance)includeinstrumentalassessments?

A‐ No.Thereareseparatecodesforinstrumentalassessments,suchasCPT92520forlaryngealfunctionstudies.

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ONE HOUR TIME BASED EVAL CODES 92626‐ EvaluationofAuditoryRehabilitationStatus;FirstHour

92627 EvaluationofAuditoryRehabilitationStatus;Eachaddition30minutes

96125‐ Standardizedcognitiveperformancetesting(e.g.,RossInformationProcessingAssessment)perhourofaqualifiedhealthcareprofessional'stime,bothface‐to‐facetimeadministeringteststothepatientandtimeinterpretingthesetestresultsandpreparingthereport.PerHour.

96105‐ AssessmentofAphasia(includesassessmentofexpressiveandreceptivespeechandlanguagefunction,languagecomprehension,speechproductionability,reading,spellingand/orwritingex.byBDAE)withinterpretationandreport‐ PerHour

92607Evaluationforprescriptionforspeech‐generatingAACdevicefacetofacewiththepatient‐ FirstHour.• 92608Evaluationforprescriptionforspeech‐generatingAACdevicefacetofacewiththepatient‐

Eachadditional30minutes.

92626‐ EVALUATION OF AUDITORY REHAB STATUS Inclusions:Evaluationandtreatmentfordisordersoftheauditorysystemmaybecoveredandmedicallynecessary,forexample,whenithasbeendeterminedbyaspeech‐languagepathologistincollaborationwithanaudiologistthatthehearingimpairedbeneficiary’scurrentamplificationoptions(hearingaid,otheramplificationdeviceorcochlearimplant)willnotsufficientlymeetthepatient’sfunctionalcommunicationneeds.Audiologistsandspeech‐languagepathologistsbothevaluatebeneficiariesfordisordersoftheauditorysystemusingdifferentskillsandtechniques,butonlyspeech‐languagepathologistsmayprovidetreatment.

96125‐ STANDARDIZED COGNITIVE PERFORMANCE TESTING Inclusions‐ Standardizedcognitiveperformancetesting(e.g.,RossInformationProcessingAssessment)perhourofaqualifiedhealthcareprofessional'stime,bothface‐to‐facetimeadministeringteststothepatientandtimeinterpretingthesetestresultsandpreparingthereport.PerHour

Includescriterionreferencedmeasureswhichcombinestandardizedmeasures

96105‐ ASSESSMENT OF APHASIA Inclusions‐ AssessmentofAphasia(includesassessmentofexpressiveandreceptivespeechandlanguagefunction,languagecomprehension,speechproductionability,reading,spellingand/orwritingex.byBDAE)withinterpretationandreport‐ PerHour

BILLING TIME BASED CODES

CodesaretimedandbasedonONEHOUR increments.

Thenumberofunitsbilledarebasedontime: 0units=0‐30minutes 1unit=31‐90minutesand 2units=91‐150minutesandsoon.

Billingbelow31minutesisnotrecommended.

TIME BASED:MED AVERSUS MED B MedicarePartA

MDSSectionO:RulesforRecordingTreatmentMinutes (RAIManual,Chapter3,SectionO;directly‐quotedtextisinitalics) Thetherapist'stimespentondocumentationoroninitialevaluationisnotincluded (PageO17)

Thetherapist'stimespentonsubsequentreevaluations,conductedaspartofthetreatmentprocess,shouldbecounted (PageO17)

http://www.asha.org/Practice/reimbursement/medicare/Medicare‐Guidance‐for‐SLP‐Services‐in‐Skilled‐Nursing‐Facilities/

MedicarePartB 96105and96125billingforMedicarePartBbeneficiariesfollowsthe

definitionofcodessetforthperLCDdefinitionsthereforeallowingSTtoaccountforinterpretationtimeinassessment.

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96105/96125“INTERPRETATION TIME”MED B 96105/96125definitionsincludelanguagewhichallowstherapisttocountinterpretationforreviewofdataobtainedduringevaluation.

96125allowsforuseofnorm‐referenced(resultsareinterpretedbasedonestablishednormsandcomparetest‐takerstoeachother)and/orcriterion‐referenced(resultsareinterpretedbasedontheperson’sperformance/abilitytocompletetasksordemonstrateknowledgeofaspecifictopic).

96105allowsfornorm‐referencedmeasuresfromstandardizedassessmentofAphasia(e.g.BDAE)

92607‐ EVALUATION FOR PRESCRIPTION FOR SPEECH

GENERATING AACDEVICE

Inclusions‐ Evaluationforprescriptionforspeech‐generatingAACdevicefacetofacewiththepatient‐ FirstHour.Rec31mins minimum• 92608Evaluationforprescriptionforspeech‐generatingAACdevicefaceto

facewiththepatient‐ Eachadditional30minutes.

PotentialICD‐9Codesappropriateforuse Codetheunderlyingcognitive;expressive/receptivelanguage;and/ormotorspeechimpairmentthatnecessitatesneedforAACdevice.

CASE STUDIES‐ EVAL CODING

Ms.Jonesrequiresevaluationofexpressive/receptivelanguage;motorspeechandvoicesecondarytoprogressionofParkinson’sdisease.Coding: 92523and92522 92523and92524 92522and92524

CASE STUDIESMr.SmithisadmittedtoSNFfollowingacuteonsetofRCVArequiringstandardizedmeasureoflanguageandcognitivefunctions 96105‐ AssessmentofAphasiaAND/OR 96125‐ StandardizedCognitivePerformanceTesting**Thinkaboutclinicalappropriatenesswhenselectingevaluationtype**WillImentallyfatigueifIassessallareasdayone?

After6weeksofintensivetreatmentyoudeterminehewillrequirespeechgeneratingAACdevicetomeetcommunicativeneeds. Use92607‐ EvaluationforprescriptionforspeechgeneratingAACDevice

CASE STUDIESMr.Smithisreferredforevaluationduetostuttering.HepresentswithAdvancedDementia.

Remember‐ DysfluencyservicesarenottypicallycoveredbyMedicare,norwouldinterventionsaimedatfluencybesupportedbyEvidencedBasedPracticePatterns.

Use92523Eval ofSpeechSoundProductionwithEval ofLanguageComprehensionandExpressionAND/OR

96105‐ AssessmentofAphasiaifpatternsfollowdiagnosticcriteriaforPrimaryProgressiveAphasiaassociatedwithDementiaOR

96125‐ StandardizedCognitivePerformanceTestinginclusiveofDementiaStagingToolswhendiseaseprocessfollowsADtypeDementia.

CPT‐ TreatmentCodes

925269250797532

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92526‐ DYSPHAGIA THERAPYPatient/caregivertraininginfeeding/swallowingtechniquesProperheadandbodypositioningAmountofintakeperswallowAppropriatediet(determining)textureandviscosityMeansoffacilitatingtheswallowFeedingtechniquesandneedforselfhelpeating/feedingdevicesFacilitationofmorenormaltoneororalfacilitationtechniquesLaryngealelevationtrainingCompensatorySwallowtechniquesOralsensitivitytrainingTechniquestoreduceshortnessofbreathoffatigueduringdurationofmeal.

DYSPHAGIA PER MEDICARE MANUAL

Dysphagia,ordifficultyinswallowing,cancausefoodtoentertheairway,resultingincoughing,choking,pulmonaryproblems,aspirationorinadequatenutritionandhydrationwithresultantweightloss,failuretothrive,pneumoniaanddeath.

Mostoftenduetocomplexneurologicaland/orstructuralimpairmentsincludingheadandnecktrauma,cerebrovascularaccident,neuromusculardegenerativediseases,headandneckcancer,dementias,andencephalopathies.Forthesereasons,itisimportantthatonlyqualifiedprofessionalswithspecifictrainingandexperienceinthisdisorderprovideevaluationandtreatment.(MBPM,2016)

SPECIALIZED DYSPHAGIA CAREPer the Medicare Benefit Policy Manual definition of SLP Scope: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; and developing a treatment plan employing appropriate compensations and therapy techniques (MBPM, 2016). 

THINK…WHAT MAKES MY SERVICES UNIQUE?HowdoyoueducatePatient/caregivertraininginfeeding/swallowingtechniques?Whatchangesaremadetohead&bodypositioningAmountofintakeperswallow(specific)Appropriatediet(determining)textureandviscosityMeansoffacilitatingtheswallowFeedingtechniquesandneedforselfhelpeating/feedingdevicesFacilitationofmorenormaltoneororalfacilitationtechniquesLaryngealelevationtrainingCompensatorySwallowtechniquesOralsensitivitytrainingTechniquestoreduceshortnessofbreathoffatigueduringdurationofmeal

VerbalUnderstanding/ReturnDemo

SPECIFIC‐ tsp;tbsp;#oftrials;goalsrelatedtoPOdiet/therapeuticportion

RelationtoInstrumental

MEASURES:BORG,PulseOx,amountoftimepriorto,signsafter.

NOW…HOW AM IDOCUMENTING THIS?DailyNoteSample1:PatientseenwithnoonmealforskilledST,likesmechanicalmeats,nursingfed100%ofthetime,verbalcuetositupstraight

DailyNoteSample2:PatientreceivedtherapeuticPOtrialsofmechanicalsoftmeatsatnoonmeal,notedincreasedbolusformationwhenpresentedin1tbsp sizebolusasevidencedbyreducedoralstasisthroughoutoralcavitys/pswallow,educationprovidedtoCNAstaffwithnotedverbalunderstandingandreturndemonstrationoftechniqueon7/10trials

92507TREATMENT OF SPEECH,LANGUAGE,VOICE,COMMUNICATION,AUDITORY PROCESSING

Skilledinterventionsaimedat:

Increasingexpressivelanguageskillsincludingabilitytocommunicatewantsandneedsandtreatmentstoaddressappropriatesyntaxandmorphology.Increasereceptivelanguageskillsforcomprehensionofspokenandwrittenlanguageimpactingabilitytorespondtoquestions,followdirections,andcomprehendstructuredandspontaneousinteractionswithothers.Increasingspeechintelligibilityskillsincludinginterventionsaimedatimprovingarticulatorypatternsandaddressingmotorspeechimpairmentssuchasapraxiaofspeechanddysarthria.Improvingpragmaticlanguageskillsrelatedtosocialaspectsofcommunicationincludingadequateknowledgeanduseofrulesforconversationandstory‐tellingandappropriateadaptationsoflanguagebasedonsettingandconversationalpartner.Increasevocalfunctionrelatedtorespiration,phonation,resonance,andpitch.Auralrehabilitationincludingprovisionofspeechreading.Traininganduseofnon‐speechgeneratingaugmentativeandalternativecommunication(AAC).Trainingandmodificationintheuseofavoiceprosthetic.

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97532‐ DEVELOPMENT OF COGNITIVE SKILLS

97532isatimebasedcodeusedfordevelopmentofcognitiveskillstoimproveattention,memory,problemsolving(includescompensatorytraining),direct(one‐on‐one)patientcontactbytheprovider,each15minutes

1unit:8minutesto<23minutes 2units:23minutesto<38minutes 3units:38minutesto<53minutes 4units:53minutesto<68minutes 5units:68minutesto<83minutes 6units:83minutesto<98minutes

97532‐ CONSIDERATIONS FOR USE ProvidersshouldbillCPT97532onlywhencognitivetreatmentistrulyadistinct,

separateactivity.Whenappropriatediagnosticassessmentisconducted,shouldcorrespondwithnewonsetforjustificationofdecline.

Differsfromservicesprovidedfor92507‐ Treatmentofspeech,language,voice,communication,and/orauditoryprocessingdisorder;individual.

Canbeusedinconjunctionwith92526,howevershouldnotbeusedsimplyduetothefactdysphagiaservicesarebeingprovidedtoanindividualwithcognitiveimpairment.

Canonlybeusedwhenappropriatedifferentialdiagnosisiscompletedtoruleoutthefollowingasrootcause: AMSassociatedwithperiodofdeliriumincludingthoseassociatedwithinfection(UTI) Underlyinglanguageand/orauditoryimpairmentasprimarycauseofcommunication

breakdowns;

92507AND 97532CorrectCodingInitiative(CCI)Edits 92507and97532CANNOTbebilledsameday.Determiningappropriatecodinguse: DifferentialdiagnosisintorootcauseoffunctionalimpairmentsbeginsatSOC.

Examples: Residentpresentswithdecreasedabilitytofollowcommands.Rootcausecouldbe‐ Decreasedimmediatememoryfordirectives(cog);decreasedattentiontotask(cog);decreasedauditorycomprehensionofdirectives(language);decreaseauditoryacuity(AR‐ 92507perMedicareRegulations)

97532AND 92526 SLPsshouldnotbillcognitivetreatmentwhentheyprovideonlyswallowingorlanguagetreatmenttoapatientwhoalsohascognitivedisorders.

However,itmaybeappropriatetobill97532onthesamedayiftherearedistinctplansofcareandspecificgoalsandtreatmentactivitiesforcognitiveimpairmentandforswallowing

TakeHomePoint‐ Cognitiveimpairmentalonedoesnotnecessitateuseof97532.

CASE STUDIES:97532;92526 Ms.SmithpresentswithasevereoropharyngealdysphagiafollowingTBIwithresultingincreasedoralprocessingofbolus,anteriorspillage,pocketing/stasisaftertheswallow,delayedinitiationofpharyngealswallowandoverts/saspirationwithintake.Deficitsarecompoundedbycognitiveimpairmentsincludingimpulsivitywithintake.

Anticipatedinterventioncoding: 92526forSwallowingTherapy 97532forCognitiveinterventionsr/timpulsivityanddecreasedattentiontotask.

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CASE STUDIES:92526;92507 Mr.Jonespresentswithprogressionofdementiawithresultingdecreasedoralcoordination,anteriorloss,increasedprocessinganddecreasedabilitytofollowbasiccommandsatmealsinordertoincreaseabilitytofollowswallowstrategies.

Anticipatedinterventioncoding: 92526forincreasingswallowfunctions 92507forincreasingsuccesswithabilitytofollowcommands.NotelanguagePOCmaybemaintenancebasedinnatureinthatinterventionswillbeshortterminordertoestablish/traincaregiverregardingtechniques.

COMPETENCY CHECK‐WHAT WOULD YOU DO?

MRS.RAY‐ FREQUENT FALLSMrs.RaywasreferredforSpeechTherapyservicessecondarytoincreasedfallsinherroom. DuringinitialpatientinterviewyounotethatMrs.RaypresentswithdecreasedabilitytoverballysequencestepsforADLtasksshepreferstocompleteinherroom(I)including:transferringfromherbedtothewalker;completingdenturecare;andcompletingUBdressingtasks.Youdeterminetherootcauseofherimpairmentsisbasedondeclinesinherreceptivelanguageabilitiesinadditiontodeclinesinexpressivelanguagelimitingherabilitytoformulatethoughtsandrequestassistancefromcaregivers. Anticipatedinterventioncoding:92507languagebasedinterventionsappeartobemostappropriatetomeethercurrentneeds.

MR.SMITH‐ FREQUENT FALLSMr.SmithwasreferredforSpeechTherapyservicessecondarytofrequentfallswhichoccurinhisroom.Hewasadmittedtoyourfacility~1weekagos/pTBIwhichoccurredinthehomeenvironment.BaselinemeasuresduringSTevaluationrevealintactlanguageabilities,howeverhepresentswithsignificantdeclinesincause‐effectproblemsolvingandshorttermmemorytasks.FallsappeartobesubsequenttooveralldecreasedabilitytonegotiateobstaclesinroomenvironmentwhenperformingADLtasks. Anticipatedinterventioncoding‐ 97532toaddresscognitiveimpairmentsrelatedtomemoryandproblemsolving.

MEDICARE BENEFIT POLICY MANUAL

CHAPTER15“REASONABLE AND NECESSARY”

INDICATIONS FOR SPEECH THERAPY SERVICES Speech‐languagepathologyservicesarethoseservicesprovidedwithinthescopeofpracticeofspeech‐languagepathologists

Necessaryforthediagnosisandtreatmentofspeechandlanguagedisorders,whichresultincommunicationdisabilitiesandforthediagnosisandtreatmentofswallowingdisorders(dysphagia)

Regardlessofthepresenceofacommunicationdisability.

(SeeCMSPublication100‐03,MedicareNationalCoverageDeterminations(NCD)Manual,Part3,Section170.3)(CMSPublication100‐02,MedicareBenefitPolicyManual,Chapter15,Section230.3(A))

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“REASONABLE AND NECESSARY”EVIDENCED BASED PRACTICE

Theservicesshallbeconsideredunderacceptedstandardsofmedicalpractice tobeaspecificandeffectivetreatmentforthepatient'scondition.Acceptablepracticesfortherapyservicesarefoundin: Medicaremanuals(suchasthismanualandPublications100‐03and100‐04), ContractorsLocalCoverageDeterminations(LCDsandNCDsareavailable

ontheMedicareCoverageDatabase:http://www.cms.hhs.gov/mcdand Guidelinesandliteratureoftheprofessionsofphysicaltherapy,occupational

therapyandspeech‐languagepathology.

Tobeconsideredreasonableandnecessary,thefollowingconditionsmustbemet:(CMSPublication100‐02,MedicareBenefitPolicyManual,Chapter15,Section220.2(B))

“REASONABLE AND NECESSARY”COMPLEXITY AND SOPHISTICATION

Theservicesshallbeofsuchalevelofcomplexityandsophistication ortheconditionofthepatientshallbesuchthattheservicesrequiredcanbesafelyandeffectivelyperformedonlybyaqualifiedtherapist

Servicesthatdonotrequiretheperformanceorsupervisionofatherapistarenotskilledandarenotconsideredreasonableornecessarytherapyservices,eveniftheyareperformedorsupervisedbyaqualifiedprofessional.

Ifthecontractordeterminestheservicesfurnishedwereofatypethatcouldhavebeensafelyandeffectivelyperformedonlybyorunderthesupervisionofsuchaqualifiedprofessional,itshallpresumethatsuchserviceswereproperlysupervisedwhenrequired.However,thispresumptionisrebuttable,and,ifinthecourseofprocessingclaimsitfindsthatservicesarenotbeingfurnishedunderpropersupervision,itshalldenytheclaimandbringthismattertotheattentionoftheDivisionofSurveyandCertificationoftheRegionalOffice.

Tobeconsideredreasonableandnecessary,thefollowingconditionsmustbemet:(CMSPublication100‐02,MedicareBenefitPolicyManual,Chapter15,Section220.2(B))

“REASONABLE AND NECESSARY”MEDICAL DIAGNOSES

Whileabeneficiary'sparticularmedicalconditionisavalidfactorindecidingifskilledtherapyservicesareneeded,abeneficiary'sdiagnosisorprognosisshouldneverbethesolefactorindecidingthataserviceisorisnotskilled.Thekeyissueiswhethertheskillsofaqualifiedtherapistareneededtotreattheillnessorinjury,orwhethertheservicescanbecarriedoutbynonskilled personnel.SeeitemCfordescriptionsofskilled(rehabilitative)services.

Tobeconsideredreasonableandnecessary,thefollowingconditionsmustbemet:(CMSPublication100‐02,MedicareBenefitPolicyManual,Chapter15,Section220.2(B))

“REASONABLE AND NECESSARY”DETERMINING APPROPRIATE FREQUENCY AND DURATION

Theremustbeanexpectationthatthepatient'sconditionwillimprovesignificantlyinareasonable(andgenerallypredictable)periodoftime,ortheservicesmustbenecessaryfortheestablishmentofasafeandeffectivemaintenanceprogramrequiredinconnectionwithaspecificdiseasestate.Inthecaseofaprogressivedegenerativedisease,servicemaybeintermittentlynecessarytodeterminetheneedforassistiveequipmentand/orestablishaprogramtomaximizefunction(seeitemDfordescriptionsofmaintenanceservices);and

Theamount,frequency,anddurationoftheservicesmustbereasonableunderacceptedstandardsofpractice.Thecontractorshallconsultlocalprofessionalsorthestateornationaltherapyassociationsinthedevelopmentofanyutilizationguidelines.

PLAN OF CARE REQUIREMENTS

STEPS

Step1:OrderReceivedStep2:ScreenStep3:EvaluateandDetermineifSkilledInterventionisNecessaryStep4:EstablishPOCStep5:WriteClarificationOrderStep6:GetPOCCertifiedStep7:ReEval asappropriateStep8:Recertifywhennecessary

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OVERVIEW:PLAN OF CARE (POC)REQUIREMENTS

OrderorReferral CleardistinctionforEvaluation/Re‐evaluationorScreening Beneficiary'sHistory andtheOnsetorExacerbationDateofthecurrentdisorder. Historyinconjunctioncurrentsymptomsmustestablishsupportforadditional

treatment. PriorLevelofFunctioningshouldbedocumented Baselineabilitiesshouldbedocumented PLOF+Baselineestablishthebasisforthetherapeuticinterventions. Plan,Goals(realistic,long‐term,functionalgoals) Duration oftherapy,Frequency oftherapy,anddefinitionoftheTypeofService. Diagnosticandassessmenttestingservicestoascertainthetype,causalfactor(s)

shouldbeidentifiedduringtheevaluation. Clarifyifplanisanticipatedtoberehabilitative/restorativeormaintenancebased

STEP1:ORDER/REFERRAL Neededforinitialevaluation MDsignatureonPOCactsascertification/clarificationofservicesafterevaluation

Newsignature/certificationneededfor: AnysignificantupdatestoPOCaffectingLTG(willrequirere‐eval orrecertification)

Additionofnewinterventionsnotincludedoninitialplan. Example‐STbeginsservicesfordysphagiaalone,asresidentprogresseswithlaryngealfunctionfurthereval iswarrantedforvoiceandmotorspeech

PTcompletesinitialPOCforwoundcareandprogressespatienttopointwherestandardPTeval isreasonableandnecessary

RecertificationofPOC

STEP2:“SCREENING” Screeningassessmentsarenon‐coveredandshouldnotbebilled.

Theinitialscreeningassessmentsofpatientsorregularroutinereassessmentsofpatientsarenotcovered.

Think…..ScreeningTellsyouEval orNotEvalNoClinicalJudgmentsorSkilledRecommendationsShouldbeMadefromScreenAlone

STEP3:EVALUATION Theorderorreferralfortheevaluationandanyspecifictestinginareasofconcernshouldbedesignatedbythereferringphysicianinconsultationwiththetherapist.

Thedocumentationoftheevaluationorre‐evaluationbythetherapistshoulddemonstratethatanactualhands‐onassessmentoccurredtosupportthemedicalnecessityforreimbursementoftheevaluationorre‐evaluation.

DETERMINESNEEDFORSKILL

EVALUATION DEFINEDEVALUATIONisaseparatelypayablecomprehensiveserviceprovidedbyaclinician,asdefinedabove,thatrequiresprofessionalskillstomakeclinicaljudgmentsaboutconditionsforwhichservicesareindicatedbasedonobjectivemeasurementsandsubjectiveevaluationsofpatientperformanceandfunctionalabilities(BASELINES).

Evaluationiswarrantede.g.,foranewdiagnosis(changefromplof).

Theseevaluativejudgmentsareessentialtodevelopmentoftheplanofcare,includinggoalsandtheselectionofinterventions.

MEDICAL HISTORY

OnsetorExacerbationDate

Onset/ExacerbationDate:thedateofthefunctionalchangewhichasaresultofdxindicatedtheneedforskilledcare

ChronicConditions:Maynotbethedateofdxforcondition,howeverrelatedtoexacerbationofdxprocess

NewConditions:CVA/TBIwillbedateofnewinsult

Inconjunctioncurrentsymptoms

Providecorrelationofwhynewonsethasresultedinsymptomsrequiringyouruniqueskilledservices.

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DETERMINE NEED FOR SKILL

EvidencedBasedPractice

ComplexityandSophistication

MedicalDiagnoses

IndividualizedFrequencyandDuration

“REASONABLE AND NECESSARY”EVIDENCED BASED PRACTICE

Theservicesshallbeconsideredunderacceptedstandardsofmedicalpractice tobeaspecificandeffectivetreatmentforthepatient'scondition.Acceptablepracticesfortherapyservicesarefoundin: Medicaremanuals(suchasthismanualandPublications100‐03and100‐04), ContractorsLocalCoverageDeterminations(LCDsandNCDsareavailable

ontheMedicareCoverageDatabase:http://www.cms.hhs.gov/mcdand Guidelinesandliteratureoftheprofessionsofphysicaltherapy,occupational

therapyandspeech‐languagepathology.

Tobeconsideredreasonableandnecessary,thefollowingconditionsmustbemet:(CMSPublication100‐02,MedicareBenefitPolicyManual,Chapter15,Section220.2(B))

“REASONABLE AND NECESSARY”COMPLEXITY AND SOPHISTICATION

Theservicesshallbeofsuchalevelofcomplexityandsophistication ortheconditionofthepatientshallbesuchthattheservicesrequiredcanbesafelyandeffectivelyperformedonlybyaqualifiedtherapist

Servicesthatdonotrequiretheperformanceorsupervisionofatherapistarenotskilledandarenotconsideredreasonableornecessarytherapyservices,eveniftheyareperformedorsupervisedbyaqualifiedprofessional.

Ifthecontractordeterminestheservicesfurnishedwereofatypethatcouldhavebeensafelyandeffectivelyperformedonlybyorunderthesupervisionofsuchaqualifiedprofessional,itshallpresumethatsuchserviceswereproperlysupervisedwhenrequired.However,thispresumptionisrebuttable,and,ifinthecourseofprocessingclaimsitfindsthatservicesarenotbeingfurnishedunderpropersupervision,itshalldenytheclaimandbringthismattertotheattentionoftheDivisionofSurveyandCertificationoftheRegionalOffice.

Tobeconsideredreasonableandnecessary,thefollowingconditionsmustbemet:(CMSPublication100‐02,MedicareBenefitPolicyManual,Chapter15,Section220.2(B))

“REASONABLE AND NECESSARY”MEDICAL DIAGNOSES

Whileabeneficiary'sparticularmedicalconditionisavalidfactorindecidingifskilledtherapyservicesareneeded,abeneficiary'sdiagnosisorprognosisshouldneverbethesolefactorindecidingthataserviceisorisnotskilled.Thekeyissueiswhethertheskillsofaqualifiedtherapistareneededtotreattheillnessorinjury,orwhethertheservicescanbecarriedoutbynonskilled personnel.SeeitemCfordescriptionsofskilled(rehabilitative)services.

Tobeconsideredreasonableandnecessary,thefollowingconditionsmustbemet:(CMSPublication100‐02,MedicareBenefitPolicyManual,Chapter15,Section220.2(B))

“REASONABLE AND NECESSARY”DETERMINING APPROPRIATE FREQUENCY AND DURATION

Theremustbeanexpectationthatthepatient'sconditionwillimprovesignificantlyinareasonable(andgenerallypredictable)periodoftime,ortheservicesmustbenecessaryfortheestablishmentofasafeandeffectivemaintenanceprogramrequiredinconnectionwithaspecificdiseasestate.Inthecaseofaprogressivedegenerativedisease,servicemaybeintermittentlynecessarytodeterminetheneedforassistiveequipmentand/orestablishaprogramtomaximizefunction(seeitemDfordescriptionsofmaintenanceservices);and

Theamount,frequency,anddurationoftheservicesmustbereasonableunderacceptedstandardsofpractice.Thecontractorshallconsultlocalprofessionalsorthestateornationaltherapyassociationsinthedevelopmentofanyutilizationguidelines.

TREATMENT:“SKILLED PROCEDURES” Analysisofactualprogresstowardgoals.

Establishmentoftreatmentgoalsspecifictodysfunctionanddesignedtospecificallyaddresseachproblemidentifiedininitialassessment.

Theselectionandinitialtrainingofadeviceforaugmentativeoralternativecommunicationsystems.

Patientandfamilytrainingtoaugmentrestorativetreatmentortoestablishamaintenanceprogram.Educationofstaffandfamilymustbeginatthetimeofevaluation.

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LIMITATIONS:“NOT SKILLED”

Non‐diagnostic,non‐therapeutic,routine,repetitiveandreinforcingprocedures(e.g.,thepracticingofworddrillswithoutskilledfeedback).

Procedureswhicharerepetitiveand/orthatreinforcepreviouslylearnedmaterialwhichthebeneficiary,stafforfamilymaybeinstructedtorepeat.

Procedureswhichmaybeeffectivelycarriedoutwiththebeneficiarybyanynon‐professional(familyorrestorativeaide)afterinstructioniscompleted.

REHAB THERAPY DEFINED

Rehabilitative/Restorativetherapyincludesservicesdesignedtoaddressrecoveryorimprovementinfunctionand,whenpossible,restorationtoapreviouslevelofhealthandwell‐being(i.e.PLOF).

Therefore,evaluation,re‐evaluationandassessmentdocumentedintheProgressReportshoulddescribeobjectivemeasurementswhich,whencompared,showimprovementsinfunction,decreaseinseverityorrationalizationforanoptimisticoutlooktojustifycontinuedtreatment.

MAINTENANCE PROGRAMS DEFINED

MAINTENANCEPROGRAM(MP)meansaprogramestablishedbyatherapistthatconsistsofactivitiesand/ormechanismsthatwillassistabeneficiaryinmaximizingormaintainingtheprogressheorshehasmadeduringtherapyortopreventorslowfurtherdeteriorationduetoadiseaseorillness.

INDIVIDUALS WITH CHRONIC CONDITIONS Rehabilitativetherapymaybeneeded,andimprovementinapatient’sconditionmayoccur,evenwhenachronic,progressive,degenerative,orterminalconditionexists.

Forexample,aterminallyillpatientmaybegintoexhibitself‐care,mobility,and/orsafetydependencerequiringskilledtherapyservices.Thefactthatfull(fullmovementfrombaselinetoplof)orpartialrecoveryisnotpossibledoesnotnecessarilymeanthatskilledtherapyisnotneededtoimprovethepatient’sconditionortomaximizehis/herfunctionalabilities.

Thedecidingfactorsarealwayswhethertheservicesareconsideredreasonable,effectivetreatmentsforthepatient’sconditionandrequiretheskillsofatherapist,orwhethertheycanbesafelyandeffectivelycarriedoutbynon‐skilledpersonnel.

STEP 4:ESTABLISH POC

EstablishPOC:‐ Goals‐ Frequency‐ Duration‐ ComparisonofPLOFandEvaluationBaseline‐ DeficitsthatrequireskilledcareMUSThavegoals‐ NoGoal=NoTreatmentCanOccur

BASELINETheinitialassessmentestablishesthebaseline datanecessaryforevaluatingexpectedrehabilitationpotential,settingrealisticgoals,andmeasuringcommunicationstatusatperiodicintervals.

Methodsforobtainingbaseline functionshouldincludeobjectiveorsubjectivebaselinediagnostictesting(standardizedornon‐standardized)followedbyinterpretationoftestresults,andclinicalfindings.

Goalsshouldnotbecreatedforareaswhichdonothavedocumentedbaselinemeasures,hence“DNT”or“WillnotbeaddressedduringPOC”shouldnotbeusedfortargetareas

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DIAGNOSTIC TESTING Diagnosticandassessmenttestingservicestoascertainthetype,causalfactor(s)shouldbeidentifiedduringtheevaluation.

Includesstandardizedandnon‐standardizedfunctionalassessmenttools.

WherecanIfindtheseresources??

PRIOR LEVEL OF FUNCTION

Theresidents’priorleveloffunctionreferstothefunctionallevelofindependencepriortoonsetofdeclinewhichnecessitatedneedforskilledtherapyscreening,andifdeemednecessary,furtherevaluationandskilledintervention.

THE SPACE BETWEEN

GreaterLevelofSupportNeededforSuccess

LowerLevelsofSupportNeededforSuccess

TheDifferencebetweenbaselineandplof measuresshouldassistthetherapistwithdeterminingappropriatefrequencyanddurationofcare.

Greaterchangesmayrequiremoreintensiveinterventions

GOALS/TREATMENT MEASURES

REALISTIC/LONGTERM/FUNCTIONAL Thereshouldbeanexpectationofmeasurablefunctionalimprovement.

Measureablecomponent(percentile)needstobeattachedtoallshortandlongtermgoals

Functionalcomponent(inorderto…)needstobeattachedtoallshortandlongtermgoals.

SUB‐TASKfunctionalimpairmentareasinordertomeasuremorespecificchangesinfunction

FREQUENCY AND DURATION Thefrequencyreferstothenumberoftimesinaweek or#ofvisitsovera

specifictimeframethetypeoftreatmentisprovided.

Theduration isthenumberofweeks,orthenumberoftreatmentsessions,forTHISPLANofcare.

Iftheepisodeofcareisanticipatedtoextendbeyondthe90calendardaylimitforcertificationofaplan,itisdesirable,althoughnotrequired,thattheclinicianalsoestimatethedurationoftheentireepisodeofcareinthissetting.

FrequencyandDurationshouldbepatientspecific,relatedtoleveloffunctionaldecline,andappropriatebasedonevidencedbasedpracticepatterns.

FREQUENCY AND DURATION CHANGES Thefrequency orduration ofthetreatmentmaynotbeusedaloneto

determinemedicalnecessity,buttheyshouldbeconsideredwithotherfactorssuchascondition,progress,andtreatmenttypetoprovidethemosteffectiveandefficientmeanstoachievethepatients’goals. Forexample,itmaybeclinicallyappropriate,medicallynecessary,mostefficient

andeffectivetoprovideshorttermintensivetreatmentorlongertermandlessfrequenttreatmentdependingontheindividuals’needs.

Itmaybeappropriatefortherapiststotaperthefrequencyofvisitsasthepatientprogressestowardanindependentorcaregiverassistedself‐managementprogramwiththeintentofimprovingoutcomesandlimitingtreatmenttime. Think…AstheSpace Between decreases,preparationsfordischarge

planningshouldbeinaction,frequencyshouldbetapered,inordertopromotecarryoverofnewlylearnedskillsandpromotehighestlevelofindependenceupond/cfromskilledcare

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STEP 5:WRITE CLARIFICATION ORDER

Patienttoreceiveskilled(insertdiscipline)(insertfrequency)(insertduration)inorderto(insertreason)

STEP 6:CERTIFICATION OF EVAL/POC CERTIFICATIONisthePhysician’s/NonPhysicianPractitioner’s(NPP)approvaloftheplanofcare(evaluation).

Certificationrequires SignaturemustbefromthephysicianorNPP Timelycertificationoccurswithin30days Adatedsignatureontheplanofcareorsomeotherdocumentthatindicatesapprovaloftheplanofcare

Wheninitialcertexpires,arecert mustthenbecompletedcertifiedwithin30days(needsMDsignatureanddatewhichcanbeaddedasreceiptdate).

STEP 7:RE‐EVAL AS NEEDED Re‐evaluationmaybecoveredifnecessarybecauseofachangeinthebeneficiary'scondition.

(CMSPublication100‐02,MedicareBenefitPolicyManual,Chapter15,Section220.3.C)

Coveredonlyifthedocumentationsupportstheneedforfurthertestsandmeasurementsaftertheinitialevaluation.

Indicationsforare‐evaluationincludenewclinicalfindings,asignificantchangeinthepatient'scondition,orfailuretorespondtothetherapeuticinterventionsoutlinedintheplanofcare.

Maybeappropriatepriortoplanneddischargeforthepurposesofdeterminingwhethergoalshavebeenmet,orfortheuseofthephysicianorthetreatmentsettingatwhichtreatmentwillbecontinued.

Continuousassessmentofthepatient'sprogressisacomponentofongoingtherapyservicesandisnotpayableasare‐evaluation.

Are‐evaluationisnotaroutine,recurringservicebutisfocusedonevaluationofprogresstowardcurrentgoals,makingaprofessionaljudgmentaboutcontinuedcare,modifyinggoalsand/ortreatmentorterminatingservices.

RE‐ EVALUATIONS ARE NOT

STEP 8:RECERT WHEN NECESSARY

Requirescompletionofrecert documentwithinOptima

RequiresMDsignatureobtainedintimelymanner(30days)

Additionalclarificationorders

REAL WORLD APPLICATION

ASHAPRACTICEPORTALShttp://www.asha.org/practice‐portal/Contain:EvidencedBasedMaps;ClinicalToolsAphasia;Dementia;HearingLoss;TBIinAdults

ASHAPREFERREDPRACTICEPATTERNShttp://www.asha.org/policy/PP2004‐00191/

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MAINTENANCE PROGRAMS

Theservicesofamaintenanceprogramthemselvesarenotcovered.However,thedevelopmentofafunctionaltreatmentplanforpatientmaintenanceincludingevaluation,planoftreatment,andstaffandfamilytraining,iscovered,butitmustrequiretheskillsofanSLP,andbeadistinctandseparateservicewhichcanonlybedonesafelybyaSLP

DOCUMENTING “ABILITY TO LEARN” Documentationisexpectedtosupporttheabilityofthebeneficiarytolearnandretaininstruction.

Absenceofsuchdocumentationmayresultinadenialofservices.

Ifthepatienthasquestionablecognitiveskills,abriefcognitive‐communicationassessmentshouldbeperformedinordertoestablishthepatient'slearningability.Thebriefcognitiveassessmentmayalsodeterminetheneedformorecomprehensivecognitiveperformancetesting.

TREATMENT MEASURES

Thereshouldbeanexpectationofmeasurablefunctional improvement.

Think…. Measureablecomponent(percentile)needstobeattachedtoallshortandlongtermgoals

Functionalcomponent(inorderto…)needstobeattachedtoallshortandlongtermgoals.

TREATMENT:“SKILLED PROCEDURES” Designofatreatmentprogramaddressingthebeneficiary'sdisorder.Continuedassessmentandanalysisduringtheimplementationoftheservicesisexpectedatregularintervals.

Establishmentofcompensatoryskillsforcommunication(e.g.,airinjectiontechniquesorwordfindingstrategies).

Establishmentofahierarchyofspeech‐languagetasksandcueinghatdirectsabeneficiarytowardcommunicationgoals.

TREATMENT:“SKILLED PROCEDURES” Analysisofactualprogresstowardgoals.

Establishmentoftreatmentgoalsspecifictospeechdysfunctionanddesignedtospecificallyaddresseachproblemidentifiedininitialassessment.

Theselectionandinitialtrainingofadeviceforaugmentativeoralternativecommunicationsystems.

Patientandfamilytrainingtoaugmentrestorativetreatmentortoestablishamaintenanceprogram.Educationofstaffandfamilymustbeginatthetimeofevaluation.

LIMITATIONS:“NOT SKILLED”

ServicesrenderedbyaSLPassistantoraide. Provisionofpracticeforuseofaugmentativeoralternativecommunicationsystemsafterbeingtaughttheiruse.

Althoughspeech‐languagepathologistsmayperformlaryngoscopyfortheassessmentofvoiceproductionandvocalfunction,laryngoscopyformedicaldiagnosticpurposesmustbeperformedbyaphysician.

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LIMITATIONS:“NOT SKILLED”

Non‐diagnostic,non‐therapeutic,routine,repetitiveandreinforcingprocedures(e.g.,thepracticingofworddrillswithoutskilledfeedback).

Procedureswhicharerepetitiveand/orthatreinforcepreviouslylearnedmaterialwhichthebeneficiary,stafforfamilymaybeinstructedtorepeat.

Procedureswhichmaybeeffectivelycarriedoutwiththebeneficiarybyanynon‐professional(familyorrestorativeaide)afterinstructioniscompleted.

AURAL REHAB Theterms,auralrehabilitation,auditoryrehabilitation,auditoryprocessing,lipreadingandspeechreadingareamongthetermsusedtodescribecoveredservicesrelatedtoperceptionandcomprehensionofsoundthroughtheauditorysystem. (CMSPublication100‐02,MedicareBenefitPolicyManual,Chapter15,Section230.3.D.3)

Coverageforspeechreadingisonlyallowedwithdocumentationthatsupportsalossofhearingsensitivitythatcannotbecorrectedwithahearingaidoramplification.Documentationshouldalsosupportvisualacuityofthebeneficiarysufficienttoparticipateinauralrehabilitation.

AURAL REHAB:“MEDICAL NECESSITY” Speechreadingisconsideredmedicallynecessarywhendeterminedbyalicensedaudiologistthattheuseofahearingaidorotheramplificationwouldnotsignificantlyimprovethebeneficiary'sunderstandingofspeech.

Speechreadingtrainingisnotmedicallynecessaryforbeneficiarieswhorefusetowearahearingaid.Routinescreeningforhearingacuityorevaluationsaimedattheuseofhearingaidsisnotacoveredservice.

DETERMINATION OF THE MEDICAL NECESSITY FOR THE SPEECH

READING WILL BE BASED ON THE FOLLOWING CRITERIA: Documentationofbasichearingevaluationandaudiogram; Documentationidentifyingtypeandextentofhearingloss; Documentationofadequatecognitiveandmemoryskills; Documentationthatvisualacuity,withglassesifapplicable,issufficienttoallowthebeneficiarytoparticipateinthetherapy;

Documentationofthebeneficiary'smotivationtoparticipateintherapyinordertoimproveunderstandingofspeech.

SeeCMSPublication100‐02,MedicareBenefitPolicyManual,Chapter15,Section230.3.D.3formoreinformationonauralrehabilitation.

COGNITIVE IMPAIRMENTS :“MEMORY AIDES” Speech‐languagepathologyservicesprovidedforchronicdisordersofmemoryandorientationarecoveredserviceswhensignificantfunctionalprogressisdemonstratedatearlystagesofthedisorder.Whenfunctionalprogressplateaus,thedevelopmentofamaintenanceprogram,includingtrainingofcaregiversandfamilymembersiscovered

Preparationofmemoryaidssuchasmemorybooks,memoryboards,orcommunicationbooksmaybecovered.Supervisionoftheuseofsuchaidsisnotcoveredastheseservicesdonotrequiretheskillsofaqualifiedtherapist.

MEDICAL DIAGNOSES “NOT COVERED” Thefollowingdisordersaretypicallynon‐coveredforthegeriatricMedicarebeneficiary: Fluencydisorder Conceptualhandicap Dysprosody Stutteringandcluttering(exceptneurogenicstutteringcausedbyacquiredbraindamage)

Myofunctional disorders,e.g.,tonguethrust

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ENGLISH AS A SECOND LANGUAGE

SpeechtherapyinterventionstoinstructthebeneficiaryinEnglishphrases,whohasaprimarylanguageotherthanEnglish,arenotcovered.

However,whentheprimarylanguageofthebeneficiaryisotherthanEnglish,speechtherapyinterventionsinthepatient'sprimarylanguagewillbecoveredwithintheparametersofthisLCD.

CAN ISKILL FOR THAT?? Nursingrefersaresidentfordietchangeduetoloosingtheirdentures FamilyrefersanewresidentforARservicesafterreceivingacochlear

implant Daughterofaresidentwithadvanceddementiawantstreatmentbecause

hermom“stutters” AnewadmissioncurrentlyonABTforUTIisreferredforcognitivetherapy

dueto“behaviors” YourfacilityMDSCoordinatorrefersaresidentwhopresentswith

decreasedBIMSscoresinSectionCoftheMDS YourRehabDirectorrefersaresidentforspeechclaritybecause“his

denturesmovearoundwhenhetalks” ThefacilityAdministratorwantsyouandOTtobothtreatapatientfor

problemsolvingbecause“ifyoubothtreat,theywillgetbettersooner”

TREATMENT PLANNINGMAINTENANCE OR REHAB?

CASE STUDY‐ “REHAB THERAPY”Ms.JonesisreferredforBedsideSwallowEvaluation,baselinemeasuresrevealmoderateoropharyngealdysphagiawithsignificantimpairmentsinoralprocessingandcoughing/wetvoiceaftertheswallowwithregulartexturesandthinliquids

STdeterminesinitiallyfrequencyanddurationof5timesaweekfor4weeksisessentialinordertoincreaseswallowfunction,allowforLRPOdietandpreventaspirationrisks

REHAB TO MAINTENANCE

After4weeksoftreatment,Ms.SmithhasincreasedswallowfunctiontoSUP.

Inordertopromotecarryoverandprepareford/cfrequencyisdecreasedto3timesaweek

PLOF=IndependentCLOF=Supervision

THE JIMMO AFFECT….CAN’T ITREAT ANYONE NOW?

ClarifiedwithJimmo versusSebelius FinalRuling: EstablishmentorDesignofaMaintenanceProgram Delivery/PerformanceofaMaintenanceProgram DeliveryofRehabilitative/RestorativeTherapy

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MAINTENANCE SAMPLE:VOICEMotorSpeech/Voice:SkilledSTservicesmaybedeemedreasonableandnecessaryinordertomaintainvocalclarityandintensityforanindividualwithParkinson’sDiseaseinordertocontinuetrainingviauseofLeeSilvermanVoiceTherapy(LSVT)techniquesformaintenance.Note:transitionfromtherapyservicesaimedatincreasingfunctiontomaintenancetherapyshouldoccurfollowingtherapist/residentdeterminationthatmaxbenefithasbeenachievedataparticularcommunicationlevel(word,phase,sentence,structuredconversation,orspontaneousconversation)withmaintenanceinterventionsbeingaimedatcontinuedcommunicationsuccess(pendingmodificationswhichmaybewarrantedsecondarytotypicaldeclineswithdiseaseprogression)atthislevelatadecreasedintensityfrompriorservices.

Whycantheseservicesnotbetransitionedtoanon‐skilledprofessionalsuchasaCNAorNurseforrestorative/maintenance?Duetotheprogressivenatureofvocalandmotorspeechsystemchanges,theskilledeyeofanSLPisneededtodevelopandcontinuevocalfunctionprotocolandconductdifferentialdiagnosiswhenchangesoccuracrossvarioussystemsofcommunicationwithdiseaseprogression.

MAINTENANCE SAMPLE:COG‐LANGUAGEAuditoryComprehension/Cognition:SkilledSTservicesmaybedeemedreasonableandnecessaryinordertomaintainauditorycomprehensionskillsinthefollowinginstances:Anindividuals/pnewneurologicalinsultfollowingaperiodofintensiveskilledSTinterventionsaimedatincreasingabilitiestocomprehendlanguageandperformcognitivetasks(sequencing,problemsolving)atthehighestlevelpossiblecontinuedservicesformaintenancemaybewarrantedtocontinueskilledtherapeutictasksforhighleveltasksinordertopreventfunctionaldeclinesinpreparationford/ctopriorlivingenvironmentwhilecontinuedservicesarebeingprovidedbyPT/OT.Interventionsprovidedasmaintenanceversusrehabilitationinnaturearetobeprovidedatadecreasedintensityfrominitialservices.

Whycantheseservicesnotbetransitionedtoanon‐skilledprofessional?Skilledinterventionsforhighlevelauditorycomprehensiontasksincludingabilitytofollowmulti‐stepADL/IADLcommands;comprehendconversationalinteractions;sequenceduringtasksandcompletefunctionalproblemsolvingwithothersrequiresadministrationoftaskswhichcannotbeperformedorconductedbyanon‐skilledprofessional.Inaddition,tasksintheaboveinstancewillrequireperiodicmodificationsecondarytoanticipatedincreasedsuccesswithPT/OTsessionswhichwillchangetasksegmentationandprogressionofADLsandIADLs.Remember‐ casessuchasdescribedmayalsomovefromrehabilitativeinnaturetomaintenancetoreturntorehabilitativeinnaturesecondarytoincreasedphysicalabilitiesnecessitatingtheneedforhigherlevelcognitiveandlanguagelearning.

MAINTENANCE SAMPLE:DYSPHAGIASkilledtherapyservicesmaybedeemedreasonableandnecessaryinordertomaintainadequateswallowfunctionsforpleasurefeedingregimentwhichisclearlydefinedandagreeduponbymembersoftheinterdisciplinaryteaminconjunctionwiththeresidentandfamilymembers.

Whycantheseservicesnotbetransitionedtoanon‐skilledprofessional?

PertheMedicareBenefitPolicyManual(2014):

Swallowingassessmentandrehabilitationarehighlyspecializedservices.Theprofessionalrenderingcaremusthaveeducation,experienceanddemonstratedcompetencies.Competenciesincludebutarenotlimitedto:identifyingabnormalupperaerodigestive tractstructureandfunction;conductinganoral,pharyngeal,laryngealandrespiratoryfunctionexaminationasitrelatestothefunctionalassessmentofswallowing;recommendingmethodsoforalintakeandriskprecautions;anddevelopingatreatmentplanemployingappropriatecompensationsandtherapytechniques.

Abovecompetenciescannotbeperformedbyanon‐skilledprofessionalinanindividualpresentingwithdysphagiaseveritywhichwouldwarrantpleasurefeedings.

Note‐ needforpleasurefeedingsmustbenecessitatedbyadysphagiasecondarytooral,pharyngeal,and/orupper1/3rdoftheesophagealphase.Servicesformaintenanceinendstageofdementiasecondarytopresenceoftonguethrustasrootcauseoresophagealimpairments/strictures/blockagesinthelower2/3rdoftheesophaguswouldnotwarrantservicesastheyarenotcoveredfortheMedicareBeneficiary.

GOAL BUILDING

CONSIDERATIONS PRIOR TO CREATING GOALSStepOne:Whatisthegapbetweencurrentbaselineandtheindividualspriorleveloffunction?WhatintensityofservicesareneededtoreturnindividualtoPLOF?StepTwo:Whatistheindividualsdesiredlongtermoutcome?StepThree:Willtheplanberestorativeormaintenancebasedinnature?

CAN IUSE CUESIN MY GOALS? PROS

CanAssistattheStartofCarewithDocumentingstimulability fortasksandabilitytolearn

CanbebeneficialforSHORTTERMmaintenancebasedplanstoreflectlevelofassistneededfromcaregiversatendofskilledcare

Canbebeneficialforshowingincreased“I”forpatientswhenweareabletoweaninconjunctionwithreflectingincreasedfunctionalabilities

CONS IfyouuseingoalyouMUSTmeasureconsistentlyatallPRsandRECERTS

Oncedeemedrepetitiveinnaturedifficulttoshowskilledneed

Clinicianmustshowuniqueskilledneedviaincreasedoverallfunctioninconjunctionwithreductionofcues

MedicarewillNOTALLOWcontinuedskilledneedforcuesalone

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GOALS/TREATMENT MEASURES

REALISTIC/LONGTERM/FUNCTIONAL Thereshouldbeanexpectationofmeasurablefunctionalimprovement.

Measureablecomponent(percentile)needstobeattachedtoallshortandlongtermgoals

Functionalcomponent(inorderto…)needstobeattachedtoallshortandlongtermgoals.

SUB‐TASKfunctionalimpairmentareasinordertomeasuremorespecificchangesinfunction

LONG TERM VERSUS SHORT TERM GOALS LONGTERMGOALSshouldreflectthehighestlevelofdesiredfunctionanticipatedupondischarge.Inmostcaseswillbereflectiveofpatient’spriorleveloffunction(PLOF)

SHORTTERMOBJECTIVESarethesteppingstones,targetedspecificareasthatareusedtoincreaseoverallfunctioninordertoachieveLTGs

SAMPLE LONGTERM

AuditoryComprehension

PatientwillimproveauditorycomprehensiontoIndependentinordertoimprovereceptivecommunicationskills

Cognition PatientwillincreasecognitiveskillstoIndependencetoimproveabilitytoparticipateinmeaningfulinteractions

CognitiveCommunicative

Patientwillexhibitadequatecognitive‐communicativeskillsfordischargehomewithNoSupervisionwithenvironmentalmodificationsastrainingtofacilitatesafetyandindependence

MotorSpeech Patientwillincreasespeechintelligibilityatthehighestfunctionalverbalexpressionlevelto100%withfamiliarlisteners,unfamiliarlistenersandwithgroups

SHORTTERM:AUDITORY COMPREHENSION Patientwilldemonstrateauditorycomprehensionof_____ CHOOSESPECIFICLEVEL(biographicalyes/no;environmentalyes/no,simpleyes/no,complexyes/no,commonADLobjects,associationobjects/items,simplequestions,simpleinstructions/commands,complexquestions,simpleconversation,complexconversation,variouslevelsoffunctionalcommunication,specificmedications)

ADDMEASUREABLECOMPONENTwith100%accuracyandnocuesin

ADDFUNCTIONALASPECTordertoimprovereceptivecommunicationskills

SHORTTERM:AUDITORY COMPREHENSION

Patientwillfollow1‐stepcommandswith100%accuracyinordertoenhancepatient’sabilitytofollowdirectionsforactivitiesandADLs

Patientwillfollowmulti‐stepverbalcommandswith100%accuracyand25%verbalcuesinordertoenhancepatient’sabilitytoincreaseabilitytoparticipateinADLs

ExpressiveLanguage Establishandadvancegoalsacrosscommunicationlevelsfromautomatics;word‐

conversation

ReceptiveLanguage Respondingtoyes/no,openendedversusclosedended?’s

Swallowing Breakdowngoalsbyphaseofswallow‐ oralprep,oral,pharyngeal,upper1/3rd

esophageal

Voice Obtainbaselinesonspecificareas‐ quality,pitch,intensityandcreategoalsacrossthese

areas

Cognition Rememberhigherlevelexecutivefunctionincludesmanyareas‐ breakdownspecifically

forproblemsolving,sequencingandinstrumentalactivitiesofdailyliving.

REMEMBER TO SUB‐TASK

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PARTII:PUTTINGTHEPIECESTOGETHER

DOCUMENTATION& GOALBUILDING

Regulations Incorporatinginto DocumentationThepatient'smedicalrecordmustcontaindocumentationthatfullysupportsthemedicalnecessityforservicesincludedwithinthisLCD.(See"IndicationsandLimitationsofCoverage.")

ProperlydocumentdeclinesfromPLOFwhenmeasuringbaselines;utilize“summary”sectionofevaluationtoindividualizePOCandpaintofclearpictureofhowdeclineshaveaffectedqualityoflife;properlycode“diagnosesthatindicatemedicalnecessity”

Documentationincludes,butisnotlimitedto,relevantmedicalhistory,physicalexamination, resultsofpertinentdiagnostictestsorprocedures.

Utilize“Reasonfor Referral”,“PMH”sectionofevaluationtodocument“relevantmedicalhistory”(e.g.documentingpresenceofParkinson’sDiseasewhenprovidingtreatmentforhypokineticdysarthria)

Notonlyshoulddocumentationdescribetheconditionofthepatientthatnecessitatestheskilledinterventionofthespeech‐languagepathologist,butshouldalsoreportclinicaljudgmentanddescribetheskillednature ofthetreatment.

Clinicianshoulduseskillsettoanalyze patient’sresponsetointerventionsonadailybasisadjustingPOCtomeetpatient’sneedsutilizingtheirbest“clinicaljudgment”(e.g.“Basedonpatient’sdecreasedattentionspanfortaskcompletioningroupsettingswithotherresidents,STwillinitiatetargetstoaddressimpairmentsinordertopromotefollowthroughofnewlylearnedskillsintosettingsoutsideofST”)Rememberdefinitionof“skilled”servicesrequiretheuniqueskillsetofatherapist

Regulations Incorporatinginto Documentation

Documentingtheskilledcomponentsofactivitieswillassistinsupportingthattheservicesaremedicallynecessary.

Includes, treatmentplandevelopment,strategies, hierarchyoftasks,cueinghat,analysisofprogress,establishmentofspecificgoals,selectionandinitialtrainingofAAC,patientandfamilytraining

Documentationofspeechlanguageservices,likeothertherapyservices,mustbeobjective,clear,concise,andmustshowevidenceofthebeneficiary'sprogress inmeetingtreatmentgoals.

Utilize builderstoappropriatelycreatetargetsforareasofimpairmentonevaluation

Documentation intheclinicalrecordmustbedescriptive,clearlyrelatedtofunctionality,andcomplementandcorrelatewithotherdisciplines.

Descriptive‐ DocumentallskilledinterventionsinTENS,PR,utilizeAddendumasneeded.

Clearlyrelated toFunctionality‐ tie “inorderto”portiontogoals

Regulations IncorporatingintoDocumentation

Medicalnecessitymaynotbeestablishedifthereisconflictingdocumentationbetweendisciplinesorwidelyfluctuatingabilitiesindicatinganunstablecondition.

Keepopen linesofcommunicationbetweeninterdisciplinarystaff

Priorleveloffunctioningmustbedocumentedandconsideredinthepatient'streatmentplan,toestablishreasonablegoalsforthepatient'spresentcondition.

Always documentpriorleveloffunctionforareasthatwillbetargetedduringplanofcare;thismayrequirecontactingPOA,familymembersinordertoensureaccuratemeasure

Statementssuchas"mildlyimpairedtomoderatelyimpaired"or"fairplustogoodminus"donotoffersufficientobjectiveandmeasurableinformationtosupportprogressandmayresultindenialofservicesasnotmedicallynecessary.

Effectivelyutilizegoalbuilderssystemtomeasureshorttermtargetsviauseofpercentilestiedtofunction.USE

1. Patientwillexhibitfunctionalcause/effectproblemsolvingskills100%ofattemptsand25%verbalcuesinordertofacilitatedecisionmakingskillscare/needs.VERSUS

2. PatientwillperformfunctionalproblemsolvingtaskswithIndependence

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Regulations Incorporatinginto Documentation

Documentationofdischargeplanningshouldbeindicatedearlyinthetreatmentplan.

Utilize“AssessmentSummary/PatientcaregivereducationsectiontodocumenttrainingprovidedtopromotecarryoverintosettingsoutsideofST;Complete“PatientResponse”sectionthat allowsstatementsregardingprogresstowardsPOC;decreasefrequencyofvisitsaswarrantedinprepford/c.

Whereavalidexpectationofimprovementexistedatthetimeserviceswereinitiated,orthereafter,theservicesmaybecoveredeventhoughtheexpectationmaynotberealized.

EstablishPOCto outline“expected”outcomes,howeverbeflexible/fluidandmakechangesaswarrantedviadischarging/addingnewtargets;changingfrequency/durations;incorporatingvarioustreatmentapproaches.Utilize“patientresponse”sectionofPR

Progressreportsmustdocumentacontinuedreasonableexpectationthatthepatient'sconditionwillimprovesignificantly,i.e.,ameasurableandsubstantialincreaseinthepatient'slevelofcommunication,independence,andfunctionalcompetencecomparedtothelevelwhentreatmentwasinitiated.

Completethorough progressreportsensuringtoobtainmeasuresofallshorttermandlongtermgoals

Regulations IncorporatingintoDocumentation

Documentationshouldincludeimprovements,setbacks,andinterveningmedicalcomplications—whateverisdeemedpertinenttojustifytheneedforcontinuedintervention.

Improvementsshouldbeappropriately documentedonPRsviauseoffunctional,measureabletargets.Utilize the“AdditionalAnalysis”sectionofProgressReportstodocument“setbacks”and“interveningmedicalcomplications”

GO TO RESOURCES

New2014Eval Codeshttp://www.asha.org/Practice/reimbursement/coding/New‐CPT‐Evaluation‐Codes‐for‐SLPs/

MedicareBenefitPolicyManualChapter15http://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/downloads/bp102c15.pdf

ASHA‐ MedicareCPTCodingRulesforSLPhttp://www.asha.org/Practice/reimbursement/medicare/SLP_coding_rules/

MedicareGuidanceforSLPServicesinSkilledNursingFacilities(SNFs)http://www.asha.org/Practice/reimbursement/medicare/Medicare‐Guidance‐for‐SLP‐Services‐in‐Skilled‐Nursing‐Facilities/

REFERENCESASHA(2016).CodingforReimbursementFrequentlyAskedQuestions:Speech‐LanguagePathology.http://www.asha.org/practice/reimbursement/coding/coding_faqs_slp.htm

ASHA(2016).MedicareCPTCodingRulesforSpeech‐LanguagePathologyServices.http://www.asha.org/practice/reimbursement/medicare/SLP_coding_rules/

Brown,J. & Satterfield,L.(2012,May15).BottomLine:Co‐BillingofCognitive,DysphagiaCodes.TheASHALeader.

CMSPublication100‐03,MedicareNationalCoverageDeterminations(NCD)Manual,Part3,Section170.3)(CMSPublication100‐02,MedicareBenefitPolicyManual,Chapter15,Section230.3