Transcript Dysphagia Therapy in Adult Settings- Providing Skilled Services and

Dysphagia Therapy in Adult
Settings- Providing Skilled Services
and Documenting Medical
Necessity
Amber Heape, MCD, CCC-SLP, CDP
Clinical Specialist- PruittHealth
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
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.
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)
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
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
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
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
Documentation
• If you don’t document it, you didn’t do it!
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
Evaluations
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
Precautions
State code status. Any medical conditions that would prevent use of
NMES? Risk of Aspiration? Altered diet or liquid consistencies.
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
History/Medical
required from therapy by Medicare - only what is pertinent to what
Complexities/Patient therapy will be working on. Also, do not paint a picture of the patient
Factors
that is negative: i.e. drug abuser, non-compliant, etc.
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
Prior Residence and extensive prior living arrangements helps to set up appropriate
Living Arrangement interventions and goals.
Discharge
What support will patient have upon discharge from therapy?
Environmental
Factors/Social
Support
Evaluations
Rehab potential
Prognostic
Indicators
This 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.
Patient is able to follow directions, patient receives support from
caregivers, patient is motivated, recent medical decline, independent
prior level of function.
Previous Therapy
State 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 Plans
Document 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.
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.
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.)
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
Treatment Billing Should Include
•
•
•
•
Date
Type of treatment/modality
Time treated
Professional credentials
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.
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
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)
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
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?
Goal Writing Examples
Goal Writing Activity…
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?