If we were to create a "perfect" situation in which to provide services, one of the things we might be tempted to do would be to eliminate the need for paperwork. Then we could spend all of our time with the patient. However, in the "real" situations in which we work, documenting what we do is as important as providing the service. A report issued last year from the Office of the Inspector General in the Department of Health and Human Services served to remind us of that fact. The report, "Physical, Occupational, and Speech Therapy for Medicare Nursing Home Patients – Medical Necessity, Cost and Documentation Under the $1,500 Caps," concluded that 14% percent of SNF rehabilitation services were medically unnecessary, based solely on a sample review of medical record documentation.
Speech-language pathologists who work with adults in any setting who have communication and swallowing problems must understand Medicare regulations and must realize that the only way a claims reviewer can make a judgment about compliance is to read our documentation.
Medicare defines some key terms that guide us when making decisions about which patients should be seen for therapy and when discharge should occur. Medicare pays for services that are reasonable, provided with appropriate frequency and duration, and necessary, meaning the therapy provided is appropriate for the patient’s diagnosis. Common reasons that therapy might be deemed not necessary and appropriate include the patient not being well enough to participate in treatment, or having a low level of endurance that interferes with participation. The services must also be specific, effective, and skilled. That is, the therapy must target particular treatment goals and must be likely to achieve improvement within a reasonable period of time.
Reasons for Denials
When analyzing treatment plans and progress notes, the reviewer might deny charges if:
The therapy also must occur at an appropriate frequency and with appropriate length of sessions. Unfortunately, there are no specific guidelines given about what is an appropriate length of session or frequency. The therapy must require the knowledge, skills, and judgment that only the certified and licensed SLP can provide. If a patient were judged to be maintaining skills, rather than gaining skills, this would not require the ongoing skilled services of an SLP. Moreover, Medicare does cover several sessions for training family and caregivers in the implementation of a maintenance program.
Regardless of the setting, when the SLP receives a referral for evaluation, there must be a written or telephoned physician’s order for the evaluation. Some fiscal intermediaries allow nurse practitioners or physician assistants to order, certify, and recertify services. Each setting has requirements about how quickly the evaluation must be completed to comply with its rules.
The evaluation should clearly indicate the medical diagnosis (sometimes called secondary diagnosis) that appears to be the cause of the communication/swallowing problem for which the patient was referred. If this is not clear in the medical record, consultation with the physician may be indicated. The evaluation should describe the history of the patient’s communication/swallowing problem, the current level of functioning, and a treatment diagnosis. Diagnoses might utilize wording such as moderate expressive aphasia, moderate oral dysphagia with suspected pharyngeal dysphag ia, moderate flaccid dysarthria, or moderate verbal apraxia. Describing the current level of functioning should utilize wording understandable to others who are not SLPs. For example, the current level of functioning of a patient with moderate flaccid dysarthria might be described as "patient’s speech is very difficult to understand unless the context is known." Of course, if you are a registered user of ASHA’s National Outcomes Measurement System (NOMS), the Functional Communication Measures provide an excellent way to describe and rate current function.
A treatment plan must be established that includes long- and short-term goals, and each should be written in functional terms that are understandable to everyone. For example, a long-term goal might be worded, "Patient will be able to eat and drink foods of normal texture without choking or aspirating." This long-term goal might have several short-term goals, each worded functionally: "Patient will improve the timing of closure of the larynx to keep food from falling into the airway when swallowing;" "Patient will improve lifting of the larynx to reduce residue which may fall into the airway;" and "Patient will improve tongue movement to reduce food residue remaining in the mouth after the swallow." The treatment plan should list a prognosis for improvement, estimated length of treatment, and frequency and duration of sessions. The prognosis should be specific to the long-term goal. That is, it is not helpful to write that the prognosis is "good" without specifying what the goal is. It is more meaningful to write, "Prognosis is good that patient will be able to eat normal foods and liquids." Ideally the treatment plan should be signed (and returned if an outpatient setting) by the physician before treatment begins. However, most intermediaries use language such as "returned as soon as possible."
Some documentation must occur for each therapy session. This may be called a treatment log or daily notes. At a minimum, the daily note should include date and time (time started and stopped), total treatment time with the patient, and who provided the therapy. Since short-term goals are usually meant to be accomplished over a period of several weeks to a month, it is helpful if specific treatment objectives, or treatment techniques, are described that are being used to achieve the short-term goals. For example, if treating reduced laryngeal elevation, a progress note might reflect how well the patient did with the Mendelsohn maneuver and with production of falsetto, thus allowing you to use percentages to describe levels of change on these specific tasks designed to help the patient achieve the short-term goal.
Patients are "reevaluated" in every therapy session, with SLPs watching closely for signs that the patient has stopped progressing, has become ill and can’t participate, or has met some goals and is ready to have other short-term goals added. However, it is important that at least monthly this "reevaluation" be clearly documented in the chart, confirming if there is a need for continued therapy. Depending on whether the patient is receiving services under Medicare Part A or Part B, there are differences in what happens with this reevaluation information.
Finally, when the patient is discharged, a discharge summary should be written that summarizes the treatment the patient received. If you are practicing in an outpatient setting, a copy of this discharge summary should be sent to the physician. This lets the physician know the patient’s current level of functioning.
Though we all get frustrated at the amount of paperwork that has to be done, it is crucial that we clearly document what we did, why we did it, and what the results were. It is only through clear documentation that we can demonstrate that patients are receiving appropriate services.