Clinicians often seek guidelines on the amount and duration of speech-language pathology and swallowing services to provide patients; clinicians in skillled nursing facilities often feel pressured to provide maximum care that they may view as inappropriate.
Clinicians will find guidance on treatment amount and duration in three ASHA documents—Model Medicare Review Guidelines for Speech-Language Pathology (based on Medicare's original guidelines), especially the section defining "medically necessary services," Model Medical Review Guidelines for Dysphagia, and Ethics in Reimbursement—and the National Outcome Measurement System (NOMS), which provides treatment frequency data and outcomes.
Clinicians can use all these resources to educate employers and supervisors about appropriate levels of care and to caution them about potential audits and site visits. Each source has information to assist clinicians to establish patient selection criteria, develop treatment goals, and make discharge decisions.
ASHA's Model Medical Review Guidelines for Speech-Language Pathology defines covered speech-language pathology services as "reasonable and necessary for the treatment of the individual's illness or injury." The guidelines state that the services must be specific and effective treatment for the patient's condition; be of such a level of complexity and sophistication that they can be performed only by or under the supervision of a qualified speech-language pathologist; that there must be an expectation that the patient's condition will improve significantly in a reasonable time period; and that the amount, frequency, and duration of services be reasonable under accepted standards of practice.
For guidance, private health plans and organizations that review Medicare claims are referred to local SLPs, the state speech-language-hearing association, or ASHA for the development of utilization guidelines.
The guidelines further note that if an individual's expected restoration potential would be insignificant in relation to the "extent and duration" of services required to achieve such potential, the services are not considered medically necessary. If at any point in treatment it is determined that the expectations will not be realized, the services should no longer constitute covered speech-language pathology services. If restoration potential is judged insignificant or it plateaus, a maintenance program may be established.
ASHA's Model Medical Review Guidelines for Dysphagia report similar conditions. As the guidelines note, "as with all rehabilitation services, there must be a reasonable expectation that the patient will make material improvement within a reasonable period of time. The establishment of a functional maintenance program by a therapist may be an acceptable goal when further clinical improvement is unlikely."
ASHA's Code of Ethics provides additional guidance on decisions about patient care, particularly as it relates to reimbursement. Ethics violations include:
- Misrepresenting information to obtain reimbursement or funding, such as using a code for the sole purpose of reimbursement
- Providing service when there is no reasonable expectation of significant communication or swallowing benefit for the person served
- Scheduling services more frequently or for longer than is reasonably necessary
- Requiring staff to provide more hours of care than can be justified in a prospective payment environment
ASHA's Code of Ethics attempts to place the profession well above legal standards. The Office of the Inspector General (OIG) in the federal Department of Health and Human Services monitors and prosecutes Medicare and Medicaid fraud and abuse committed by providers. Fraud occurs when a provider intentionally attempts to defraud the government by committing a crime such as billing for services never provided; abuse may entail such activities as improper billing, excessive charges for services, and filing claims for services that are not medically necessary.
In a Board of Ethics Issues in Ethics Statement, ASHA concludes that with regard to ethics and reimbursement, "the paramount rule for ensuring proper representations in connection with diagnosis and treatment is that professionals must follow their own best clinical judgment in formulating diagnoses, prognoses, and treatment plans."
This last statement empowers clinicians to be in charge. Your professional training, skill, and judgment support the patient care decisions you make. You have leverage (defined as "the power to act or influence") when justifying or not justifying treatment to administrators, supervisors, and employers. If you feel your job could be threatened if you don't follow your employer's directives, and you believe your judgment about the patient's care meets practice standards and your supervisor's or employer's does not, you might find a serious listener at 1-800-HHS-TIPS, which connects you to the OIG.
ASHA's NOMS data can be another source of guidance for patient care. NOMS is a data collection system developed to show the value of speech-language pathology and audiology services provided to adults and children with communication and swallowing disorders. NOMS uses ASHA's functional communication measures (FCMs), a series of disorder-specific, seven-point rating scales designed to describe the change in an individual's functional communication and/or swallowing ability over time.
NOMS fact sheets are available for adults in skilled nursing, acute care, and outpatient settings. For patients who received swallowing treatment in skilled nursing and who scored at an FCM level 3 on admission (i.e., they maintained less than 50% of nutrition and hydration by mouth with an alternate feeding method required), more treatment time translated into better functional outcomes. Patients progressing to level 4 received 7.4 hours of treatment, while those reaching level 5 (all nutrition/hydration by mouth with minimal diet restrictions) received 11.3 hours of treatment.
For patients with neurological disorders seen in skilled nursing, including many with swallowing problems, the average stay was 23.3 days, the typical number of sessions per week was five, and the typical session length ranged from 30 to 60 minutes. For in-depth review of NOMS data, go to the ASHA Web site.
In July 2009, clinicians can choose another option that will allow greater independence in providing speech-language pathology services. On that date, Medicare will allow SLPs in private practice to bill Medicare directly for the services they provide.