Patient Driven Payment Model Brings Opportunities for Skilled Nursing Facilities  

The Value of Speech-Language Pathology Services 

The Patient Driven Payment Model (PDPM), effective October 1, 2019, offers a unique opportunity for skilled nursing facilities (SNFs) to move beyond minutes and provide value-driven care to Medicare beneficiaries. PDPM reinforces the value of speech-language pathology in three important ways:  

1. Speech-language pathologists (SLPs) are the only therapy providers to receive additional payment for select comorbidities. 
2. Speech-language pathology services are not subject to the variable per diem rate applied to physical and occupational therapy services. Historical claims data used to develop the PDPM demonstrates that SLPs provide services consistently across the episode of care.  
3. Primary diagnosis, cognitive impairment, a diet or swallowing disorder, and/or the need for a mechanically altered diet drive payments for speech-language pathology under PDPM.

The Centers for Medicare & Medicaid Services (CMS) has clarified that the definition of skilled therapy is not changing under the PDPM. Patients from a variety of clinical backgrounds can benefit from speech-language pathology services and must receive these services when medically necessary, regardless of diagnosis.  

The Value of Retaining SLPs in Skilled Nursing Facilities 

Success Under PDPM Will Require SLPs to Assist in the Identification of Patient Needs 

SLPs play a critical role in identifying patients for treatment and determining their plan of care. Comprehensive coding that recognizes all diagnoses and comorbidities/complexities is critical.

Speech-Language Pathology Diagnosis Codes 

The International Classification of Diseases (ICD) is a list of diagnosis codes that trigger speech-language pathology payment and the speech-language pathology comorbidity payment (when an applicable comorbidity is present) is available on the CMS website (see “PDPM ICD-10 Mappings”). This list will be modified over time, as CMS refines the payment system. It is important for SLPs and SNFs to accurately and comprehensively include the specific treating diagnosis (in addition the medical diagnoses) to describe cognitive, communication, and swallowing disorders on claims  even when those codes are not yet included in the CMS list. In order for more conditions to be included in the list in the future, there must be accurate and comprehensive data submitted to CMS on the treatment conditions addressed by clinicians. 

Payment Under PDPM Will Require SLPs to Help SNFs Maintain High-Quality 

Therapists play an imperative part in quality improvement and helping to avoid payment adjustments under the value-based purchasing program (VBP), the quality reporting program (QRP), and Nursing Home Compare. 

Involve SLPs in the Completion of the Minimum Data Set (MDS) 

Engaging SLPs in the completion of relevant sections of the minimum data set (MDS) helps identify patients who need speech-language pathology services, ensures accuracy of the data, and facilitates interprofessional practice. SLPs should contribute to this process directly or in consultation with the MDS coordinator.   

• Section K: Swallowing and Nutritional Status 
  • K0100A Loss of liquids/solids from mouth when eating or drinking 
  • K0100B Holding food in mouth/cheeks or residual food in mouth after meals 
  • K0100C Coughing or choking during meals or when swallowing medications 
  • K0100D Complaints of difficulty or pain with swallowing 
  • K0100Z None of the above 
  • K0510C2 Mechanically Altered Diet While a Resident 
• Sections B & C: Cognition  
  • BIMS 
    • C0200 Repetition of three words 
    • C0300 Temporal orientation 
    • C0400 Recall 
  • CFS 
    • B0100 Coma and completely dependent or ADL did not occur 
    • C1000 Severely impaired cognitive skills (C1000 = 3) 
    • B0700, C0700, C1000 
      • Two or more of the following: 
        • B0700 >0 Problem being understood; 
        • C0700 =1 STM problem; 
        • C1000>0 Cognitive skills problem; and 
      • One or more of the following: 
        • B0700 >=2 severe problem being understood; 
        • C1000 >=2 severe cognitive skills problem 
• Sections I & O: Clinical Category 
  • I4300 Aphasia 
  • I4500 CVA, TIA, Stroke 
  • I4900 Hemiplegia or Hemiparesis  
  • I5500 Traumatic Brain Injury  
  • I8000 Laryngeal Cancer 
  • I8000 Apraxia  
  • I8000 Dysphagia 
  • I8000 ALS 
  • I8000 Oral Cancers 
  • I8000 Speech & Language Deficits 
  • O0100E2 Tracheostomy Care While a Resident 
  • O0100F2 Ventilator or Respirator While a Resident 

SLPs Help Prevent Medicare Audits by Ensuring Claims and Documentation are Complete and Accurate 

SLPs play a valuable role in managing: 

• Changes in payment that result from changes in the coding or classification of SNF patients versus actual changes in case mix. 
• Changes in the volume and intensity of therapy services provided to SNF residents under PDPM compared to resource utilization group (RUG) IV. 
• Compliance with the group and concurrent therapy limit. 
• Inappropriate increases in the use of mechanically altered diet among the SNF population that may suggest that beneficiaries are being prescribed such a diet based on facility financial considerations rather than a clinical need. 
• Potential consequences (e.g., overutilization) of using cognitive impairment as a payment classifier in the speech-language pathology component. 
• Trends in facilities where beneficiaries experience inappropriate early discharge or receive fewer services than are medically necessary (e.g., underutilization due to the variable per-diem adjustment). 
• Stroke and trauma patients, as well as those with chronic conditions, by identifying any adverse trends from application of the variable per-diem adjustment. 
• Use of the interrupted-stay policy to identify SNFs whose residents experience frequent readmission, particularly in facilities where the readmissions occur just outside the 3-day window used as part of the interrupted-stay policy. 
• Changes in quality reporting performance and star ratings that could indicate a decline in quality or patient satisfaction. 

Scope of Practice for SLPs 

SLPs engage in professional practice in the areas of communication, swallowing, and cognition across the lifespan. Communication and swallowing are broad terms encompassing many facets of function. Communication includes speech production and fluency, language, cognition, voice, resonance, and hearing. Swallowing includes all aspects of swallowing, including related feeding behaviors. Cognition includes memory, attention, problem solving, and executive functioning. 

PDPM recognizes the impact of swallowing and cognitive disorders, in particular, on patients in SNFs. For cognition, SLPs address attention, memory, problem solving, and executive functioning. CMS reinforced the role of SLPs in providing cognitive treatment as outlined in a response to ASHA that clarified billing for cognitive treatment.  

For swallowing disorders, SLPs address oral phase, pharyngeal phase, esophageal phase, and atypical eating (e.g., food selectivity/refusal, negative physiologic response). 

SLPs treat patients with a wide variety of conditions including, but not limited to: 

• neonatal problems (e.g., prematurity, low birth weight, substance exposure); 
• developmental disabilities (e.g., specific language impairment, autism spectrum disorder, dyslexia, learning disabilities, attention-deficit disorder, intellectual disabilities, unspecified neurodevelopmental disorders); 
• disorders of aerodigestive tract function (e.g., irritable larynx, chronic cough, abnormal respiratory patterns or airway protection, paradoxical vocal fold motion, tracheostomy); 
• oral anomalies (e.g., cleft lip/palate, dental malocclusion, macroglossia, oral motor dysfunction); 
• respiratory patterns and compromise (e.g., bronchopulmonary dysplasia, chronic obstructive pulmonary disease); 
• pharyngeal anomalies (e.g., upper airway obstruction, velopharyngeal insufficiency/incompetence); 
• laryngeal anomalies (e.g., vocal fold pathology, tracheal stenosis); 
• neurological disease/dysfunction (e.g., traumatic brain injury, cerebral palsy, cerebrovascular accident, dementia, Parkinson's disease, and amyotrophic lateral sclerosis); 
• psychiatric disorder (e.g., psychosis, schizophrenia); 
• genetic disorders (e.g., Down syndrome, fragile X syndrome, Rett syndrome, velocardiofacial syndrome); and 
• orofacial myofunctional disorders (e.g., habitual open-mouth posture/nasal breathing, orofacial habits, tethered oral tissues, chewing and chewing muscles, lips and tongue resting position). 

Quality Improvement 

SNFs assess its quality on a variety of externally (e.g., payer-developed) and internally developed measures. A recent analysis of publicly reported Medicare quality reporting program (QRP) data [PDF] provides an interesting snapshot of areas where SNFs have the opportunity to achieve additional gains. Such opportunities include avoiding the payment penalties associated with the QRP, improving patient quality and experience of care, and potentially achieving efficiency and reduced costs. SLPs stand ready to assist in achieving these shared goals.  

SLPs' Role in Fall Prevention 

Factors such as depression, hearing loss, medication management, cognitive impairments, and poor sleep all impact a patient's risk for falls as well as their ability to report them in a timely fashion. Good clinical practice dictates determining whether these risk factors play a role in the care of the patients in SNFs. Approximately 60% of older adults with cognitive impairment fall annually, almost two times more than their peers without a cognitive impairment (Eriksson, et al., 1993). Among individuals with dementia, fall frequency can even reach as high as 80% (Shaw et al., 2003). The high prevalence of falls among patients with dementia, despite relatively intact motor function, highlights the idea that falls are often not just a motor problem (Van Iersel, et al., 2006). Risk of persistently high expenditures for fall-related injuries among older Medicare community-dwelling fee-for-service beneficiaries, is significantly higher for individuals with cognitive impairments, which leads to hospital/facility readmissions (Hoffman, et al., 2017).  

SLPs can help detect cognitive impairment to identify older adults who are at higher risk for falling. Cognitive impairment can be a risk factor for falls and a barrier to safe/independent discharge to prior living environments consequent to the fall. SLPs have a critical role in assessing cognitive-communication and cognitive deficits in patients of all ages including patients who have had a stroke, traumatic brain injury, or suffer from a neurodegenerative condition such as Parkinson's Disease, and all forms of dementia. Appropriate referrals can help SLPs design interventions so the patient can reduce their fall risk (e.g., designing memory aids and cues to help the individual follow safety precautions and self-regulate impulsive behaviors). Emerging evidence indicates that cognitive interventions have effects that carry over from the cognitive to the physical domain to enhance gait, and may reduce fall frequency (Segev-Jacubovski, et al, 2011). 

SLPs' Role in Discharge to Home/Community 

SLPs can help increase the rate of discharge back to the community and decrease avoidable re-hospitalizations. Specifically, SLPs can positively influence the following factors that contribute to discharge back into community: 

Communication: A primary purpose for addressing communication and related disorders is to affect positive measurable and functional change(s) in a person's communication status so that they may participate in all aspects of life—social, educational, and vocational. Key considerations for treatment include maximizing improvement and/or maintenance of functional communication, evaluation of communication outcomes, and enhancement of quality of life. SLPs recognize that communication is always an interactive process and that the focus of intervention may include training of communication partners (e.g., caregivers, family members, peers, educators) and modification of communication in schools, workplaces, and other settings (ASHA, 2003). Communication is central to discharge back into the community, especially in individuals with speech/language impairments or cognitive deficits associated with a variety of diagnoses. Several studies have indicated that communicative competence predicts individuals' safe discharge back to the community. For example, a 2013 study found that deficits in auditory and reading comprehension and oral spelling to dictation were significantly associated with increased odds of discharge to a health care facility (e.g., SNF), rather than to a community-based environment, after adjustment for physical therapy and occupational therapy recommendations (González-Fernández, et al., 2013). Functional dependence and comorbidities, such as chronic aphasia, have been found to be a significant predictor of a non-home-based discharge setting in post-stroke individuals (Mees, et al., 2016). The SLP's scope of practice and unique training specifically equips them to prepare individuals to return home with appropriate communication facilitators, as needed, ensuring maximum safety. 

Cognition: Cognition is an important predictor of safety and functional independence in determining discharge to home, even in individuals undergoing purely orthopedic related rehabilitation (Ruchinskas, et al., 2000). Several studies emphasize the importance of cognition in the ability to return to completely independent living after medical rehabilitation in geriatric patients (MacNeill, et al., 1997). The Scope of Practice in Speech-Language Pathology (ASHA, 2016), as it relates to cognitive-communication impairments, indicates that the practice of speech-language pathology includes providing prevention, screening, consultation, assessment and diagnosis, treatment, intervention, management, counseling, and follow-up for disorders of cognitive aspects of communication (e.g., attention, memory, problem solving, executive functions). CMS has reinforced the role of SLPs in providing cognitive treatment as outlined in a response to ASHA seeking clarification of billing for cognitive treatment. 

Swallowing: SLPs with appropriate training and competence diagnose and manage oral and pharyngeal dysphagia. SLPs also recognize causes, signs, and symptoms of esophageal dysphagia, and make appropriate referrals for diagnosis and management. The SLP's specific role and level of involvement may vary for each clinician and across patients, work settings, and institutions. Presence of dysphagia represents a significant barrier to returning home, specifically in neurogenic diagnoses. Those individuals with dysphagia, post-stroke, are more likely to be discharged to institutional settings, such as SNFs, after inpatient stroke rehabilitation, and experience longer stays at these facilities (Nguyen, et al., 2015). Aside from the significant costs resulting from chronic dysphagia and associated care, these conditions have a negative impact on an individual's quality of life.   

Health Literacy: More than just a measurement of reading skills, health literacy also includes writing, listening, speaking, arithmetic, and conceptual knowledge. According to the IOM report (2004), health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.” Inadequate health care literacy affects all population segments but is predictably more common in certain demographic groups such as the elderly, those with limited education, members of minority groups, and recent immigrants to the United States. Patients with aphasia or other neurological disorders affecting speech, language, or cognition, or those with severe hearing loss, are at risk when presented with vitally important written or verbal medical information. In addition, patients who face the stress of a medical crisis, possibly without an advocate or significant other being present, or while in a state of pain, confusion, or depression, may have difficulty understanding written or verbal medical information. SLPs have a vital role in effective patient-provider communication. As federal laws, regulations, guidelines, and accreditation standards mandate improved patient provider communication, it is vital to maximize the SLP's contributions to this significant area of practice that impacts patients' safe discharge back to the community. Nearly half of all adult Americans—90 million people—have difficulty understanding and using health information. Further, the rate of hospitalization and use of emergency services is higher among patients with limited health literacy (Kindig, et al., 2004). Limited health literacy may lead to billions of dollars in avoidable health care costs and, more importantly, impact thousands of lives. Inadequate health literacy directly affects the physical aspects of patient safety and negatively affects the fiscal aspects of health care delivery. The costs of poor health care literacy are staggering due to longer and more frequent hospital stays, ineffective use of prescriptions, and misunderstanding treatment plans. SLPs can assist with discharge planning while considering an individual's health literacy to minimize these costs (Rasu, et al., 2015).  

SLPs' Role in Functional Goals 

Functional person-centered goals in rehabilitation directly impact an individual's return to home and participation in activities of daily living (ADLs) with maximum independence. SLP intervention in the domains of communication, swallowing, and cognition help address questions in relation to rehabilitating, maintaining, or compensating for an individual's functional abilities, such as: 

1. Can the patient communicate effectively (ranging from their basic wants and needs to complex and abstract concepts such as emotions, social communication, and health care needs)?  
2. Can the patient take nutrition, hydration, and medication safely and in adequate amounts? 
3. Is the patient safe in their living environment and what cognitive supports can be in place to ensure effective return to least restrictive living environment?  
4. What education/training is needed for patient, family, and/or caregiver to ensure safe discharge to prior level of function? 

Learn More About the Certificate of Clinical Competence (CCC) 

Being "certified" means holding ASHA's Certificate of Clinical Competence (CCC), a nationally recognized professional credential that represents a level of excellence in the field of audiology (CCC-A) or speech-language pathology (CCC-SLP). Those who have achieved the CCC, have voluntarily met rigorous academic and professional standards, typically going beyond the minimum requirements for state licensure. They have the knowledge, skills, and expertise to provide high quality clinical services, and they engage in ongoing professional development to keep their certification current. 

The standards for certification for speech-language pathology are established by SLPs who are members of ASHA's  Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC). Certificate holders are expected to uphold these standards and abide by ASHA's Code of Ethics.  

Contact ASHA Staff:   

Sarah Warren, ASHA's Director of Health Care Policy, Medicare 
swarren@asha.org

Share our clinician resources with your SLPs: The Medicare PDPM in SNFs

References 

Eriksson, S., Gustafson, Y., & Lundin-Olsson, L. (2008). Risk factors for falls in people with and without a diagnose of dementia living in residential care facilities: a prospective study. Archives of gerontology and geriatrics, 46(3), 293–306. 

Tinetti, M.E. (2003). Preventing falls in elderly persons. New England Journal of Medicine, 348(1), 42–49. 

Van Dijk, P.T., Meulenberg, O.G., Van de Sande, H.J., & Habbema, J.D.F. (1993). Falls in dementia patients. The Gerontologist, 33(2), 200–204. 

Van Iersel, M.B., Verbeek, A.L.M., Bloem, B.R., Munneke, M., Esselink, R.A., & Rikkert, M.O. (2006). Frail elderly patients with dementia go too fast. Journal of Neurology, Neurosurgery & Psychiatry, 77(7), 874–876. 

Hoffman, G.J., Hays, R.D., Shapiro, M.F., Wallace, S.P., & Ettner, S.L. (2017). The costs of fall‐related injuries among older adults: Annual per‐faller, service component, and patient out‐of‐pocket costs. Health Services Research, 52(5), 1794–1816. 

Segev-Jacubovski, O., Herman, T., Yogev-Seligmann, G., Mirelman, A., Giladi, N., & Hausdorff, J.M. (2011). The interplay between gait, falls and cognition: can cognitive therapy reduce fall risk? Expert Review of Neurotherapeutics, 11(7), 1057–1075. 

American Speech-Language-Hearing Association. (2003). Evaluating and treating communication and cognitive disorders: approaches to referral and collaboration for speech-language pathology and clinical neuropsychology [Technical Report]. Available from  www.asha.org/policy/. 

González-Fernández, M., Christian, A.B., Davis, C., & Hillis, A.E. (2013). Role of aphasia in discharge location after stroke. Archives of Physical Medicine and Rehabilitation, 94(5), 851–855. 

Mees, M., Klein, J., Yperzeele, L., Vanacker, P., & Cras, P. (2016). Predicting discharge destination after stroke: A systematic review. Clinical Neurology and Neurosurgery, 142, 15–21. 

Ruchinskas, R.A., Singer, H.K., & Repetz, N.K. (2000). Cognitive status and ambulation in geriatric rehabilitation: walking without thinking? Archives of Physical Medicine and Rehabilitation, 81(9), 1224–1228. 

MacNeill, S.E., & Lichtenberg, P.A. (1997). Home alone: The role of cognition in return to independent living. Archives of Physical Medicine and Rehabilitation, 78(7), 755–758. 

Nguyen, V.Q., PrvuBettger, J., Guerrier, T., Hirsch, M.A., Thomas, J.G., Pugh, T.M., & Rhoads 3rd, C.F. (2015). Factors associated with discharge to home versus discharge to institutional care after inpatient stroke rehabilitation. Archives of Physical Medicine and Rehabilitation, 96(7), 1297. 

Kindig, D.A., Panzer, A.M., & Nielsen-Bohlman, L. (Eds.). (2004). Health literacy: a prescription to end confusion. National Academies Press. 

Rasu, R.S., Bawa, W.A., Suminski, R., Snella, K., & Warady, B. (2015). Health literacy impact on national healthcare utilization and expenditure. International Journal of Health Policy and Management, 4(11), 747.