Harmony Healthcare Blog

Avoiding Denials: Speech Therapy Documentation in the SNF

Posted by The Harmony Team on Thu, Jul 30, 2015

Edited by Kris Mastrangelo

SpeechFirst, as with any therapy provided in the skilled nursing facility, there must be a significant decline or observation of improvement in performance with a skill once assessed as stable.  For dysphagia concerns, ensure the prior level details the patient’s previous diet as well as the ability to perform other functional tasks, such as clear his or her throat and swallow pills.  For cognitive-linguistic therapy, it is beneficial to provide anecdotal evidence of cognitive function.  For example, if the patient was able to safely navigate to a group activity every week or was independent with his or her pills and financials this would indicate a higher cognitive level.

It is also important to consider the root cause of any cognitive declines.  Medicare contractors have been very clear that they will not support services that are rendered for “transient conditions.”  For example, many patients develop cognitive difficulties in the presence of a urinary tract infection.  Theoretically, as the UTI clears, the patient’s delirium will subside as well.  Documentation must support that there has been a new onset of cognitive-linguistic deficits that are not transient but have the potential to be resolved through skilled therapy.  That is a difficult challenge, but an essential part of documentation in order to get claims paid under review.

Second, goals should be measurable, specific, and relate directly to the deficits identified and the prior level of function.  All too often evaluations make vague references to problem solving or memory and then set very specific goals.  For example:

  • Prior level of function:  Memory independent.
  • Current level of function:  Memory moderately impaired.
  • Goal:  Patient will recall 3/3 items from sentence level information after 1 minute.

Though the evaluation has all three necessary elements present, it is near impossible for the reviewer to identify the level of decline from the patient’s prior function or how relevant the goal is based on the prior and current levels of measurement.  The following example helps the reviewer better understand the patient’s deficits and goals:

  • Prior level of function:  The patient participated in monthly discussions with a book club.
  • Current level of function:  The patient was able to recall 1/4 items from paragraph level information on the SLUMS.
  • Goal:  Patient will recall 3/3 items from sentence level information after 1 minute.

The anecdotal details in the prior level of function help to determine the patient’s previous ability to recall information.  The goals are directly related to measureable data from the assessment process.

Third and finally, treatment notes must detail the skills of a therapist.  Many denials are generated when the treatment notes document the therapist feeding the patient and providing verbal cues.  The notes must detail how the cues (i.e. the teaching and training) differ from the cues that could be provided by non-skilled staff.  The same applies to cognitive-linguistic treatments.  Consider the following example:

  • Orientation:
    • Non-skilled:  Cues provided for orientation, patient able to identify person, place, and situation.
    • Skilled:   Patient questioned regarding orientation, but only able to identify person.  Patient prompted with “Look around the room; what objects in the room help you identify what place you are in?”  Patient noted folder on end table with facility name and was able to recall both place and situation.
    • Skilled:  Patient prompted with “Look around the room; what objects in the room help you identify what place you are in?”  Patient identified a bed and reported she was at home in her bedroom.  Prompted with, “Are there objects in this room that you would not find in your home?”  With additional cues for each item, patient identified the curtain around her bed, oxygen tank, and bedside commode but still could not identify her place

With the ever changing healthcare industry, the importance of having accurate speech therapy documentation is imperative for facilities in order to continue to receive accurate reimbursement for the care that is being provided.  Harmony (HHI) recommends providing ongoing education and training to facility staff to ensure all members of the Interdisciplinary team are documenting the skilled care they are providing.  Harmony (HHI) is available to assist the facility with this education upon request.  You can contact Harmony Healthcare by clicking here or calling our office at (800) 530-4413.


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Tags: Therapy Documentation, Speech Therapy

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