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Documentation of Skilled Versus Unskilled Care for Medicare Beneficiaries

Speech-Language Pathology Services

Medicare guidelines state that all services must be medically necessary and be provided at a level of complexity and sophistication that requires a speech-language pathologist to perform the tasks. They further stipulate that the interventions provided "require the expertise, knowledge, clinical judgment, decision making and abilities of a therapist that assistants, qualified personnel, caretakers or the patient cannot provide independently" (Medicare Benefit Policy Manual, Chapter 15, Section 220.3B [PDF]).

What are examples of skilled services?

Speech-language pathologists use their expert knowledge and clinical decision-making to perform the skilled services listed below.

  • Analyze medical/behavioral data and select appropriate evaluation tools/protocols to determine communication/swallowing diagnosis and prognosis.
  • Design plan of care (POC) including length of treatment; establishment of long- and short-term measurable, functional goals; and discharge criteria.
  • Develop and deliver treatment activities that follow a hierarchy of complexity to achieve the target skills for a functional goal.
  • Based on expert observation, modify activities during treatment sessions to maintain patient motivation and facilitate success.
    • Increase or decrease complexity of treatment task.
    • Increase or decrease amount or type of cuing needed.
    • Increase or decrease criteria for successful performance (accuracy, number of repetitions, response latency, etc.).
    • Introduce new tasks to evaluate patient’s ability to generalize skill.
  • Engage patients in practicing behaviors while explaining the rationale and expected results and/or providing reinforcement to help establish a new behavior or strengthen an emerging or inconsistently performed one.
  • Conduct ongoing assessment of patient response in order to modify intervention based on:
    • patient performance in treatment activities;
      • patient report of functional limitations and/or progress.
  • Ensure patient/caregiver participation and understanding of diagnosis, treatment plan, strategies, precautions, and activities through verbalization and/or return demonstration.
    Train and provide feedback to patients/caregivers in use of compensatory skills and strategies (e.g., feeding and swallowing strategies, cognitive strategies for memory and executive function).
  • Train caregivers to facilitate carry-over and generalization of skills.
  • Develop, program, and modify augmentative and alternative communication system (low tech or high tech).
  • Instruct patient and caregiver in use and care of communication system.
  • Develop maintenance program—to be carried out by patient and caregiver—to ensure optimal performance of trained skills and/or to generalize use of skills.
  • For patients with chronic or degenerative conditions, evaluate patient’s current functional performance; provide treatment to optimize current functional ability, prevent deterioration, and/or modify maintenance program (Medicare Benefit Policy Manual, Chapter 15, Section 220.2 C&D [PDF]).

What are examples of unskilled services?

Unskilled services do not require the special knowledge and skills of a speech-language pathologist. Skilled services that are not adequately documented may appear to be unskilled. Unskilled documentation examples are listed below.

  • Report on performance during activities without describing modification, feedback, or caregiver training that was provided during the session (e.g., patient was 80% accurate on divergent task; patient tolerated diet [or treatment] well).
  • Repeat the same activities as in previous sessions without noting modifications or observations that would alter future sessions, length of treatment, or POC (e.g., continue per POC, as above).
  • Report on activity without connecting the task to the long- or short-term functional goals (e.g., patient has treatment plan to address intelligibility related to dysarthria, but the note simply states "patient able to read a sentence and fill in the blank on 90% of trials").
  • Observe caregivers without providing education or feedback and/or without modifying plan.

The interpretation of Medicare guidelines and examples above are consensus-based and provided as a resource for members of the American Speech- Language-Hearing Association.


Additional Resources

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