Solid clinical documentation has long been a focus for many providers. However, since the launch of the Manual Medical Review in October of 2012, this focus has grown tremendously. The instance of denials for therapy services has grown exponentially and our single greatest weapon in recouping payment for skilled and dedicated services remains strong clinical documentation.
The Centers for Medicare and Medicaid Services (CMS) and the Medicare Administrative Contractors (MACs) regulate the documentation policies that oversee Medicare benefits for rehabilitation. CMS provides a “minimum” guideline for therapy documentation policies in the Medicare Benefit Policy Manual Chapter 15, Section 220 Coverage of Outpatient Rehabilitation Therapy Services. An individual MAC may require more specific guidelines under their Local Coverage Determination (LCD). LCDs can be found on the CMS website.
Denials and appeals ultimately relate back to the broad umbrella of medical necessity; whether a service lacks complexity, a prior level of function, or objective measures.
The following areas of documentation consistently appear as reasons for denials in dysphagia claims.
Prior Level of Function
Dysphagia claims are often denied due to lack of an objective and measurable prior level of function (PLOF) (Wisconsin Physicians Services Corporation, 2015). Medical record reviewers want to see justification for the onset of services. The PLOF provides reference for the current level of function; thus establishing a change in function and a rationalization for services. At a minimum, the PLOF should be specific to swallowing and refer to solid textures and liquid viscosities safely tolerated prior to the change in function. At best, other relative information regarding the patient’s swallow function, level of independence, cognitive function related to swallow, weight changes or history of aspiration or other respiratory complications should all be mentioned as it relates to the patient. In all, the PLOF should be relevant to the plan of care and to the patient’s needs and goals, and it should always be objective and measurable.
The prior level of function provides a relevant framework to the evaluation findings and goals. At times, writing the PLOF after writing long-term goals makes this task less daunting. It also allows for a one to one correspondence between goals and prior levels for improved structure of the overall plan.
- Example: Resident consumed mechanical soft/thin liquids in restorative dining room with minimum cues for cyclic ingestion at 3:1 solid: liquid ratio. No s/s aspiration or oral residue. No intentional weight loss x 8 months.
If the PLOF is not available at evaluation, justify proceeding with dysphagia treatment without having established a change in the patient’s function, and obtain the prior levels as soon as possible. Document the prior levels upon receipt, tying them back to the plan of care with adjustments as needed to provide the most appropriate and medically necessary plan of care to the patient. If the PLOF information is unobtainable, document why and demonstrate the clinical rationalization for proceeding with treatment without that case history component. At times it is justified, just be sure to communicate why.
Lack of Baseline Measures with Goals
Goals should have baselines at onset. Baseline measures determine the viability of goals and establish means of tracking future progress (American Speech-Language Hearing Association, 2011). Without this information, defense of denials for services including initial dates of services become cumbersome.
Once baseline measurements are established, the same type of measurement must be used throughout. Whether using percentages, a given number of trials, a level of cues, or a combination of these types, consistency is non-negotiable.
Goals Not Targeting Impairments
Whether intending to compensate or remediate, short-term goals should always target the impairments impacting swallow function. This establishes the skill and complexity of dysphagia services at the onset. To that effect, goals for exercises should be avoided. Exercises are tools for achieving goals related to impairment and function, but the completion of exercises is not a goal itself. (Centers for Medicare & Medicaid Services, 2014).
- Examples: Patient will perform cyclic ingestion at a solid: liquid ratio of 2:1 with moderate verbal cues on 9/10 trials for decreased oral residue and aspiration/choking risk.
- Patient will increase labial seal for no-minimal left anterior loss of p.o. intake given minimal verbal and tactile cues on 4/5 trials for increased intake, dignity, and quality of life.
Further, well-written goals, both short and long-term, are patient-centered, functional and measurable.
Demonstration of Skill in the Progress Note
Demonstration of skill and medical necessity of services is of the utmost importance to a Medicare reviewer. Documentation must support that not just anyone can provide the services being billed. The progress note serves as the go-to document for demonstration of skill and medical necessity (Centers for Medicare & Medicaid Services, 2014).
Demonstrate skill first through objective measures of progress in the plan of care. Remember to remain consistent for easy tracking. At times, patients suffer acute illness and exhibit no progress or even regress. If so, document the cause and the plan for treatment modification to facilitate the patient’s function moving forward (Centers for Medicare & Medicaid Services, 2014).
Further, interventions used to attain this progress should also be documented. Avoid broad descriptions such as “compensatory strategies” or “dysphagia training” and use specifics such as “effortful swallow,” or “chin tuck” and discuss the specific purpose of the intervention.
Avoid the rut of documenting the number of coughs at meals with no physiological explanation or clinical plan as this appears more like rote observation than skilled intervention. When documenting signs and symptoms of aspiration or dysphagia with trials, include descriptions of the impairment while addressing plans for remediation.
- Example: Patient showed signs of aspiration with trials of NTL on 4/10 trials with moderate verbal cues to “swallow hard”. Presents with moderately impaired tongue based retraction, impairing bolus propulsion posteriorly for effective swallow reflex coordination… Continue with progressive exercise training with increased reps x 10 of minimal pair sets and lingual resistance training for increased lingual strength.
Keep discussion and administration of exercise regimens and overall dysphagia treatment provision progressive in nature. If treatment does not seem to progress, modifications may be needed.
Lack of Goal Modifications
Sometimes goals are just right progress flows from evaluation through discharge. Other times, modifications are needed. If patients are not progressing, evaluate the plan of care. Do goals account for lower levels of functioning? If the patient has progressed beyond their goals, they may require an upgrade toward long term goals and higher levels of function. Demonstrate the skilled ability to analyze patient functionality and adjust the plan of care accordingly. At the end of each period, use the progress note to communicate what occurred and the plan moving forward, goal modifications or not, to demonstrate a clear and meaningful direction. If documentation reflects the daily clinical rationalizations of treatment; it will speak for itself.
From start to finish, solid dysphagia documentation describes the patient’s change in function, notes the disease processes that led to that change, and details the plan for correction or compensation as it occurs, noting the clinical rationalizations along the way. Demonstrate the skill and complexity of these services to facilitate appeals success.
- American Speech-Language Hearing Association. (2011). Speech-Language Pathology Medical Review Guidelines. 16.
- Centers for Medicare & Medicaid Services. (2014). Covered Medical and other Health Services. Medicare Benefit Policy Manual, Chapter 15, 164-184. (CMS Publication No. 100-02). Retrieved February 9, 2015, from http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
- Wisconsin Physicians Services Corporation. (2015). Skilled Nursing Facility (SNF) Common Reasons for Denial. Retrieved February 8, 2015, from http://www.wpsmedicare.com/j8macparta/departments/medical_review/skilled-nursing-facility.shtml