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Medicare/Medicaid. Government health care for the elderly and/or government dependentsMedicare servicescovered at a:durationintensityseverity of the impairmentbeneficiary's responseAll are concepts that are interrelated to the provision of service.. . MisconceptionsDuration and intensitynot
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1. ASC 823J: Medical Aspects of Speech Language Pathology
Medicare, Medicaid Guidelines
2. Medicare/Medicaid Government health care for the elderly and/or government dependents
Medicare services
covered at a:
duration
intensity
severity of the impairment
beneficiary’s response
All are concepts that are interrelated to the provision of service.
3. Misconceptions
Duration and intensity
not "set in stone" by reviewers
Patient diagnosis
Progressive neurologic diseases
Dementia
Time post-onset
beyond the acute epoch
Age
is not defined, should not be a factor given the other guidelines are met
4. The Glass is... Terminology issues
words/phrases used can impact the likelihood of payment
Sets the tone for expectation of progress, or necessity of skilled services
Tx can be provided in the following areas
speech
language
swallowing
voice
5. Half empty... Poor cognitive skills
Pt. not oriented to time or place
Status unchanged
Maintenance tx
Monitored during mealtime
Pt. Confused
No significant difficulties noted
Oral motor exercises were stressed
6. Half full... New skill acquired
Designed and established a functional maintenance program
Pt. ready for next step in tx
Ability to generalize noted
Higher level language skills noted
Training and instruction
Functional vocabulary increased
Deficits require skilled tx
7. Treatment Goals Measurable
Functional
Pt. Related
Focused on the areas reimbursed
at least 50%
Long term goals
level attained
Short term goals
steps taken
8. Example Training and instruction to help patient use "head down" compensatory strategy
Pt. Will demonstrate safe swallow of a 1/3 tsp pureed bolus using the "head down" with 90% effectiveness
Training and instruction in specific oral muscle movement patterns to improve safety of the swallow
Pt. Will demonstrate functional lip closure to keep food in the oral cavity for 9/10 swallows (1/3 tsp. bolus)
9. Evaluations Questions reviewers will ask when viewing eval docs.
What happened: reviewers will look for medical diagnosis associated with a specific ICD code.
When
Premorbid skill level
Current presenting problems
Prognosis for improvement
Skilled tx required?
Recommendations include functional outcomes?
10. ICD Codes Primary Codes
CVA - 436.0
Tx Codes
Apraxia - 784.69
Aphasia - 784.3
Dysarthria - 784.5
Agnosia - 784.69
Dysphagia - 787.2
Tx codes must be in line with diagnostic codes, or it may be basis for denial of payment
Codes would be on Tx plan
11. Premorbid Skills Premorbid abilities
previous CVAs
other neurologic events
normal functioning
Cannot set goals higher than the prior level of function
Current functioning
make sure to describe deficits so that reviewer can see that it is a covered aspect of speech/language and swallowing
12. Deficit statements Because of dysarthria the patient is unable to produce understandable speech to communicate wants and needs. Speech intelligibility is currently at the 20% level of effectiveness.
The aphasia has produced a symbolic dysfunction that interferes with the patient’s ability to recall and use single words to communicate wants and needs. This ability is currently at the 30% level of effectiveness.
13. Deficit statements cont’ Although these are acceptable statements according to Medicare guidelines, a clinician should question them.
What’s wrong with these statements?
You must provide the basis for your observations
Standardized tests
requires skilled administration
Informal observation
requires skilled interpretations
14. Summary of Evaluation State the medical diagnosis
Specify the date of occurrence or change in condition
Describe the conditions the you are qualified to treat
Explain why speech services are needed
Specific training and instruction that needs to be conducted
Functional levels of independence
15. Progress Notes Home health
progress report every 60 days
All other settings
progress report every 30 days
Functional goals
Need for skilled services
Progress related to functional goals
Positive expectation for improvement if the patient is to be seen for another month
16. What are "skilled services"? Diagnostic/assessment
Designing Tx plans
Establishing compensatory skills
Establishing hierarchical tasks and cueing that directs a pt. toward communication goals
Analysis related to actual progress toward goals
Patient and family training to augment tx or facilitate maintenance
17. Reimbursement for tx For services to be reimbursed by Medicare, the reviewer must feel that Pt skills were being constantly analyzed and the clinician was constantly providing feedback to facilitate positive change in behavior. Reviewers look for this in documentation
18. Progress Note Summary Functional goals addressed
Knowledge and training of a professional is necessary
Progress must be related to functional progress toward established goals
Comparison statements must be included in the documentation
Positive expectation for continued progress
19. Cautionary Note Although Medicare may only require monthly notes, if they have questions regarding tx sessions, they may want to review session notes.
Keep session notes in the same format, remembering the wording etc.
Medicare can deny payment of individual therapy sessions
20. 700 and 701 forms Necessary for home care and some medical facility situations
21. Medicare Denial Criteria Services are not reasonable nor are they necessary
Services are not considered skilled services