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.