Documentation Pitfalls—and How to Avoid Them As a Medicare Claims Reviewer for Mutual of Omaha, I have the opportunity to review numerous claims from speech-language pathologists around the country. The population that tops the list of the claims I review is patients with dysphagia. This is also the number one disorder for which claims are denied, ... Bottom Line
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Bottom Line  |   February 01, 2003
Documentation Pitfalls—and How to Avoid Them
Author Notes
  • Joe Caniglia, is a speech-language pathology claims reviewer for Mutual of Omaha and an associate professor of Speech Communication Disorders at the University of Nebraska at Omaha.
    Joe Caniglia, is a speech-language pathology claims reviewer for Mutual of Omaha and an associate professor of Speech Communication Disorders at the University of Nebraska at Omaha.×
Article Information
Swallowing, Dysphagia & Feeding Disorders / Bottom Line
Bottom Line   |   February 01, 2003
Documentation Pitfalls—and How to Avoid Them
The ASHA Leader, February 2003, Vol. 8, 14. doi:10.1044/leader.BML1.08032003.14
The ASHA Leader, February 2003, Vol. 8, 14. doi:10.1044/leader.BML1.08032003.14
As a Medicare Claims Reviewer for Mutual of Omaha, I have the opportunity to review numerous claims from speech-language pathologists around the country. The population that tops the list of the claims I review is patients with dysphagia. This is also the number one disorder for which claims are denied, particularly for patients who have the dual diagnoses of dysphagia and dementia. Below are the most common issues leading to a denial.
Skilled vs. unskilled services
  • It must be clear from the documentation that the knowledge and expertise of a trained SLP are necessary to treat the patient. For example, claims may be denied that describe treatment for diet changes or diet upgrades without providing evidence that the patient has dysphagia or that the specialized skills of an SLP are required to make the diet change.

Incomplete documentation
  • The patient’s history, current level of functioning, and swallowing complaint must be documented. Claims often lack a complete medical history or the outcome of previous dysphagia treatment the patient may have received prior to the current event.

  • Treatment goals that address pharyngeal dysphagia in the absence of documented evidence of pharyngeal swallowing problems (e.g., no instrumental evaluation, etc.) may be denied.

Lack of functional goals
  • Long- and short-term goals that are not functional in nature and address only the patient’s ability to perform exercises (e.g., “The patient will be able to perform neuromuscular exercises 60% of the time”) are subject to denial. In this example, a more functional goal would be, “The patient will improve tongue movement to reduce oral residue and decrease aspiration risk.”

Unreasonable amount of time to set up functional maintenance programs
  • The claim for the development of a maintenance program or caregiver training that takes many days or sessions to complete may be denied.

  • It should not take many sessions to monitor a patient’s feeding or carryover of compensatory strategies before the patient is discharged from services.

Inappropriate reason for evaluation/patient not appropriate for therapy
  • An example of an inappropriate referral is the patient for whom weight loss is the only reason given for an evaluation and no evidence of dysphagia is documented.

  • If documentation does not support the expectation that the patient’s condition will improve significantly within a reasonable amount of time, claims may be denied.

“Best practice” standards are not represented in the treatment plan
  • If a modified barium study is not done until well after intervention begins and there is no explanation for the delay, services may be denied. Refer to Clinical Indicators for Instrumental Assessment of Swallowing (ASHA, 2000) for a discussion of when an instrumental assessment is appropriate.

  • Techniques utilized (e.g., Mendelssohn maneuver, supraglottic swallow, etc.) should be considered “best practice” for the patient’s documented condition and the patient must demonstrate the ability to effectively perform these techniques for intervention to be considered appropriate.

Issues related to appeals
  • Many times, when a provider receives a denial for one of the reasons listed above, the appeal letter does not provide any new information. The provider will often cite Medicare regulations in the appeal, but will not provide further rationale for the medical necessity of the documented service or “fill in” the gaps in the original documentation. Appeals will not be successful in these cases.

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February 2003
Volume 8, Issue 3