1. Dysphagia Therapy in Adult Settings- Providing Skilled Services and Documenting Medical Necessity Amber Heape, MCD, CCC-SLP, CDP Clinical Specialist- PruittHealth

2. Amber Heape- Disclosures Relevant Financial Relationships: Salaried Clinical Specialist for PruittHealth Receives honoraria for CE courses and seminars taught, including this one Relevant Non-Financial Relationships: Former SCSHA Board Member

3. Learner Objectives 1.The learner will identify skilled vs. non-skilled services in the provision of services for patients with dysphagia. 2.The learner will apply definitions of skilled service to daily and weekly documentation for medical necessity of services for patients with dysphagia. 3.The learner will improve goal writing for skilled dysphagia services through synthesis of information.

4. Medicare Benefit Policy Manual Services must be – reasonable and necessary – Provided at the order/under the care of a physician – Provided under an established written plan of care (written, signed, and professional credentials listed)

5. Medicare Benefit Policy Manual Plan of Care must include (§220.3) at a minimum: – Diagnoses (medical and treatment) – Long-term treatment goals for the entire episode of care in the current setting Typically include short-term goals to track progress toward long-term goal – Type, amount, frequency, and duration of therapy services – Functional impairments (g-codes with severity modifiers) for MCB or HMOB MBPM recommends use of NOMS

6. Reasonable and Necessary Services (MBPM §230) Services should be considered acceptable standard treatment for the patient’s condition – MBPM – Local Coverage Determinations (LCDs) – Guidelines and literature of the profession (EBP) Services must be at a level of complexity that they can be effectively performed only by a therapist or under the supervision of a therapist Should be of an amount, frequency, and duration that are within accepted standards of practice

7. What is Skilled? (Per MBPM §220.2.C) Evaluations and reevaluations Establishment of goals to address problems identified in evaluation Designing a plan of care to address disorder, including goals, frequency, and duration Continued assessment and analysis at regular intervals during service implementation Instruction leading to establishment of compensatory strategies Selection of devices to replace or augment a function Training of patient, family, or caregivers to augment rehabilitative treatment

8. Jimmo vs. Sebelius Approved January 24, 2013 Prior to the Jimmo settlement, Medicare’s “Improvement Standard”- a resident had to show improvement for therapy to be covered. Now, the determining issue is whether the skilled services of a professional are needed, not if the patient will “improve” Intervention includes, establishing a RNP, modifying a program, preventing decline Important for patients with progressive disease processes

9. Documentation If you don’t document it, you didn’t do it!

10. Evaluation Standardized Test/Clinical Eval – SAFE – MASA – Clinical Bedside Evaluation – FEES – MBSS Description of deficits in phase used for diagnosis Prior level of function before decline Document decline – Weight loss – Decreased QOL 2’ altered diet texture – Decreased safe PO intake

11. Reason for Referral Why is therapy evaluating this resident? State the reason why the patient was referred. Why does the patient present with a skilled need for therapy? This should state the reason that the patient presents with a skilled need for therapy. It should not state that the resident was discharged from the hospital recently and admitted to the facility. Highlight the patient's needs and not hospitalization. Therapy Necessity Why is skilled therapy needed? Without therapy, what is patient at risk for? What decline or further issues may we see? Medications Per Medicare's documentation requirements pertaining to therapy, "Identification of the number of medications the beneficiary is taking (and type if known)." Poly-pharmacy is a risk factor for a number of conditions so discussing the number of meds shows that the patient's medical condition is complex and requires the skills of a therapist. The number of meds is required but the type is optional. Evaluations

12. PrecautionsState code status. Any medical conditions that would prevent use of NMES? Risk of Aspiration? Altered diet or liquid consistencies. History/Medical Complexities/Patient Factors Include current and past medical history relevant to the condition being treated that supports the medical necessity of the plan of care. Include applicable medical history and comorbidities that make therapy more complicated or require extra precautions. A thorough history is not required from therapy by Medicare - only what is pertinent to what therapy will be working on. Also, do not paint a picture of the patient that is negative: i.e. drug abuser, non-compliant, etc. Prior Residence and Living Arrangement The prior level of function for the patient can be 1 month or 1 year ago. Use a time frame that makes sense for that resident considering the medical course and what they are trying to achieve with therapy. For patients that are LTC and are picked up for therapy - document what the patient was able to perform previously and how much assistance was needed related to why the patient is being picked up for therapy. For skilled patients that will return to the community, documenting extensive prior living arrangements helps to set up appropriate interventions and goals. Discharge Environmental Factors/Social Support What support will patient have upon discharge from therapy? Evaluations

13. Rehab potentialThis should ideally be excellent or good. What is the patient’s potential to achieve the goals set on the plan of care? It does not mean if the resident will achieve good or excellent independent status upon discontinuation of therapy. Prognostic Indicators Patient is able to follow directions, patient receives support from caregivers, patient is motivated, recent medical decline, independent prior level of function. Previous TherapyState what therapies the patient received, where the therapy was received, and what the outcome was. If the patient is not able to recall pervious therapy and if the medical chart does not reveal this information, state that in this section. The Medicare Benefit Policy Manual states, "Record of previous episode of therapy treatment from the same or different therapy discipline in the past year." Discharge PlansDocument what the prior level was as that is what we are trying to restore the resident to. Do not predict what we think the resident will do - even if they have an extreme illness. We can't limit their potential. Evaluations

14. Weekly Progress Notes Skilled Services Provided Since Last Report- Therapist should detail what skilled treatments, activities, exercises were provided during the week. Were compensatory strategies instructed and facilitated, was biofeedback utilized, were caregivers instructed and evaluated on their ability to safely complete task? Remaining Functional Deficits-detail the underlying impairments “Pt continues to exhibit deficits in bolus manipulation and swallow initiation, which affects his ability to swallow safely. “ Impact on Burden of care- Detail if the patients current functional status has resulted in decreased level of assistance and in what functional areas or if they need more assistance from staff to complete certain tasks.

15. Weekly Progress Notes Compensatory strategies - detail what they are “Pt educated in compensatory strategy (chin tuck) to facilitate safe swallow.” Decision making related to therapy progression-detail what decisions were made, why they were made and pt’s response in therapy following the change. Patient/Caregiver Training- Always document who was trained, what the training consisted of, what is the patient or caregiver response (verbal understanding or return demonstration if appropriate.)

16. Discharge Summaries D/C Summary- This should be comparative in nature (what was functional status at evaluation vs. functional status at discharge. What progress was made?) Patient/Caregiver Training- Always document who was trained, what the training consisted of, what is the patient or caregiver response (verbal understanding or return demonstration if appropriate.) Analysis of Functional Outcome- use skilled terminology to indicate patients’ progress or lack of progress in therapy, indicate gains made, barriers to progress..this should be functional in nature) Example – Patient met self feeding goal this week. Pt’s ability to complete donning of overhead shirt is impaired due to B UE ROM deficits with the R UE exhibiting 70 degrees of active shoulder flexion and the L UE exhibiting 50 degrees of active shoulder flexion. Skilled OT services are warranted to continue to address ROM deficits and facilitate functional independence with ADL’s

17. Treatment Billing Should Include Date Type of treatment/modality Time treated Professional credentials

18. Daily Notes Justify billing codes being used. Demonstrate the skilled interventions of the therapist Must be linked to a goal. Demonstrate medical necessity. Demonstrate progression.

19. Not Skilled Determining percentage consumed Patient performed lingual exercises x 10 Patient performed chin tuck x 5 Patient pocketing food Patient coughing during meal Patient tolerated NMES for.. minutes

20. Statements to avoid… -“observed patient... “ (You are assessing or evaluating the quality!) -met maximal potential -tolerating treatment well -ROM in ranges (i.e. 25- 50% range). Use specific measurements or number of responses WFL (ex. 8/12)

21. Skilled Assessed patient’s oral intake quality and encurance Facilitated progressive resistive exercises of lingual strength in order to perform effective buccal sweep Determined appropriate compensatory strategy Instructed patient in appropriate positioning for chin tuck

22. Writing an Effective Goal 1.What symptom are you seeing? 2.What is not working (underlying mechanism of dysfunction)? 3.What task will you do to correct it?

23. Goal Writing Examples

24. Goal Writing Activity…

25. Food for Thought… Standardized Test with EVERY patient; documenting specifics, not just the name of the test Writing goals reflective of the deficits noted Breaking goals down into smaller steps, then upgrading Don’t just do exercises for exercise, why are you doing them? How are patients referred? How do I educate staff on this program? How often should I evaluate long-term patients on altered diets or PEGs?