February 18, 2003 Features
Medicare Documentation Requirements
Medicare requires that a physician evaluate each patient and establish a diagnosis before the speech-language pathologist can perform a dysphagia evaluation. The SLP's documentation must include a description of the patient's motivation, cognitive level, and alertness, in addition to a statement of the swallowing complaint. The review guidelines include a list of conditions, of which at least one must be present, for the evaluation to be conducted. This list includes, but is not limited to:
- history of aspiration or aspiration pneumonia
- choking or frequent coughing while eating
- oral motor difficulties, including drooling, food leakage, etc.
- post-surgical reaction
- presence of a tracheostomy tube or other condition that affects swallowing
Following the assessment, which includes the medical history, current eating status, and clinical observations, a care plan must be developed (see review guidelines listed above for a discussion of the need for instrumental assessment). The care plan must include goals that are specific to each identified problem. Examples of acceptable goals include:
- patient and/or caregiver training on safe swallowing techniques
- diet recommendations and modifications
- feeding techniques or use of special devices (e.g., cups, etc.) to facilitate safe feeding
- exercises designed to improve a specific problem area (e.g., increase oral motor control or tongue strength)
- training on compensatory swallowing strategies
- training in vocal cord adduction exercises to improve swallowing safety
As with all areas of service for the patient, there must be a reasonable expectation that the patient will make significant functional progress within a reasonable amount of time. It is important to ensure that all treatment goals are designed to improve the patient's safety and quality of life by reducing or eliminating the need for alternative nutrition (e.g., tube feedings) and improving oral intake and nutrition. It is also vital to ensure that all documentation supports the need for the skilled services of an SLP. Observing a patient eat a meal on a routine basis or reminding a patient to use a compensatory technique on an ongoing basis is not a skilled service and would not be reimbursed by Medicare.
View the Dysphagia Medical Review Guidelines [PDF].