Q & A
IF I WORK IN A SKILLED NURSING FACILITY DO I NEED TO SEE
A PATIENT FIVE TIMES A WEEK?
Frequency and duration issues are based on the patient’s
condition and environment. If you are told you have to see a patient
five, six, or seven times a week, this is not accurate information.
There are times when speech pathology services are the only skilled
service a patient receives. In this case, the patient must be seen
at least five times weekly to receive Medicare benefits (room and
board, medications, etc). However, most patients are receiving skilled
nursing services and possibly physical therapy and/or occupational
therapy (services that also enable a patient to receive Medicare
benefits) so it is rare that the speech pathologist would have to
see a patient five times each week. There are patients who do need
to be treated five, six, or seven times a week because of their
condition (severe dysphagia, severe aphasia, dysarthria). The decision
to see a patient five or six times per week in a skilled nursing
facility can be an appropriate option, but remember that it is the
patient’s condition and the circumstances in the patient’s
environment that determine frequency issues.
CAN I ONLY DO EVALUATIONS ON PATIENTS OR DO I HAVE TO ALWAYS
PROVIDE AT LEAST ONE OR TWO TREATMENTS AFTER THE EVALUATIONS?
Evaluations only is an acceptable practice. There are times when
your services are needed to provide specific information to help
a physician accurately assess and manage a patient. Your services
may be needed to determine if a patient has aphasia or dysphagia,
or whether a patient is a candidate for an augmentative communication
device or for non-oral feeding management. There are also times
when your evaluation indicates normal voice, speech, language, and
swallowing skills and when treatments are not indicated. These are
all appropriate and reimbursable services. Some clinicians have
reported being denied evaluations only because no recommendations
or suggestions to help a patient maintain functional speech, voice,
language, or swallowing skills were provided. Because of this, it
may be a good idea, especially if you work in home health or an
outpatient setting, to provide brief training to help a patient
maintain specific skills related to speech, voice, language, or
swallowing when you do not recommend treatment.
WHY WILL AN INTERMEDIARY IN ONE PART OF THE COUNTRY/STATE
PAY FOR A SERVICE WHEN AN INTERMEDIARY IN ANOTHER PART OF THE COUNTRY/STATE
WILL DENY THE SAME SERVICE?
Sometimes an intermediary misinterprets the guidelines. When this
happens you need to activate the appeals process. Sometimes the
guidelines are not well defined so intermediaries have the liberty
to set their own policy in that area. One example where service
guidelines are not well defined is in the area of dysphagia. The
federal government still has not issued standards for diagnostic
activities that must precede treatment. Because of this, some intermediaries
have decided to require a modified barium swallow x-ray before any
patient is seen for treatment. Other intermediaries have decided
to require an x-ray study only when a pharyngeal stage dysphagia
is suspected. There are even some intermediaries that may not allow
an x-ray study or repeat x-rays studies. In situations where your
intermediary has established their own guidelines, you will need
to contact them to explain the specific needs of your patient and
to negotiate services.
CAN THE WORD “CUEING” BE USED IN DOCUMENTATION?
Some clinicians have reported denials because the word cueing was
used. Others say they are encouraged to use this word. Some reviewers
may associate this word with drill work and may deny on this basis.
You might consider eliminating this word and substituting the words
“training and instruction”. My recommendation is that
if you use this word, describe what you were doing with the patient.
For example: Cueing provided to help patient locate appropriate
tongue position to produce “L” sound in the word leg;
redirected patient as necessary and trained in tongue elevation
SHOULD I DISCHARGE A PATIENT WHO BECOMES ILL DURING A TREATMENT
If it is anticipated that the illness will be only a few days (patient
may have the flu or be sick because a new medication is tried),
you can document these reasons and put the patient on “hold”
for several days. However, if it is anticipated that the illness
will last several weeks, discharge the patient and re-evaluate when
there is a change in condition that suggests the patient can now
benefit from your service.
CAN A PATIENT WILL APHASIA AND DYSPAGIA BE SEEN TWO TIMES
This is an acceptable and common practice. You do an evaluation
for each disorder and separate progress notes (daily and monthly)
for each disorder. You can use two separate forms for the evaluation
and monthly progress notes or you can combine your services on one
form. What is important is that your documentation reflects two
CAN I TREAT A PATIENT WITH A DIAGNOSIS OF DEMENTIA?
Medicare cannot deny your services just because you see a patient
with dementia. Medicare can, however, deny your services because
there is no expectation for progress. Medicare reviewers know that
dementia is a progressive disorder that affects cognitive skills
(reasoning, memory, judgment, generalization, attention, and/or
problem solving). Reviewers know that without these abilities a
patient is unlikely to demonstrate the ability to make progress.
So when you decide to evaluate or treat a patient with dementia,
be prepared to document positive expectation for progress. Perhaps
the patient has mild dementia with enough cognitive ability to follow
directions and attend to therapy tasks. Also, memory abilities may
be adequate for carry over. It is critical that your documentation
address these issues, especially if you are engaged in active (restorative)
Another option you have is to design and establish a functional
maintenance program. When you choose this option, you are telling
the reviewer that the patient would not benefit from active therapy
because of poor cognitive abilities. You are also saying by training
and instructing patient and caregiver, specific speech, voice, language,
and/or swallowing skills can improve. Many patients with dementia
demonstrate intact reading skills that can be sued to help the patient
compensate for specific cognitive deficits. Many speech-language
pathologists are designing memory books and memory wallets with
success because many patients with dementia can comprehend printed
material. Just remember that your goals must be related to speech,
voice, language, and/or swallowing since these are the areas recognized
by Medicare as being within the speech-language pathologist’s
scope of practice.
WHAT IS THE MINORITY STUDENT LEADERSHIP PROGRAM?
The Minority Student Leadership Program (MSLP) is a leadership
development program established for undergraduate seniors, Master’s
students, and/or AuD students who are enrolled in communication
sciences and disorders programs and PhD students who are pursing
a research doctoral degree.
WHAT IS THE PURPOSE OF THE MSLP?
- To recruit and retain racial/ethnic minorities which have been
historically under-represented in the professions of Audiology and
- To provide focused educational programming and activities to build
and enhance leadership skills.
- To provide and opportunity for program participants to interact
with leaders in the professions of audiology, speech-language pathology,
and speech, language, and hearing sciences.
WHO IS ELIGIBLE FOR THE MSLP?
Undergraduate seniors, Master’s and AuD students must be
enrolled in communication sciences and disorders programs and are
not members of ASHA
Preference will be given to students who are members of racial/ethnic
minority groups historically under-represented within ASHA, including
American Indian or Alaska native, Asian, Black or African American,
Native Hawaiian, or other Pacific Islander, and/or Hispanic/Latino.
Graduate Study – the student must be enrolled in, or accepted
for, graduate study in a communication sciences and disorders program
in the United States. Master’s degree candidates and entry
level clinical doctoral candidates must be in a program accredited
by the Council of Academic Accreditation (CAA).
PhD Track – You must be enrolled in a research doctoral degree
program. ASHA members may apply.
HOW ARE STUDENTS SELECTED FOR PARTICIPATION IN THE PROGRAM?
Forty (40) students are chosen to participate – 5 undergraduate
seniors, 20 Master’s students, 5 entry level clinical doctoral
students and up to 10 PhD students. MSLP applications are reviewed
by a panel of ASHA members and rated on the following:
- Essay: use of description, strong argument/thesis, clarity, organization,
and grammar and punctuation
- Resume: involvement in university/community activities and leadership
- Letter of support
Click here for the Minority Student Leadership Program applications.