SNF ‘Rules’: True or False? Some widespread practices in skilled nursing facilities are based on incorrect understanding of Medicare rules. We debunk 10 of the most common myths. On the Pulse
On the Pulse  |   March 01, 2017
SNF ‘Rules’: True or False?
Author Notes
  • Renee Kinder, MS, CCC-SLP, is director of clinical education for Encore Rehabilitation Services, a contract therapy provider in more than 600 facilities in 34 states. She is a member of ASHA’s Health Care Economics Committee and an affiliate of ASHA Special Interest Groups 13, Swallowing and Swallowing Disorders (Dysphagia); and 15, Gerontology, for which she serves as the professional development manager.
    Renee Kinder, MS, CCC-SLP, is director of clinical education for Encore Rehabilitation Services, a contract therapy provider in more than 600 facilities in 34 states. She is a member of ASHA’s Health Care Economics Committee and an affiliate of ASHA Special Interest Groups 13, Swallowing and Swallowing Disorders (Dysphagia); and 15, Gerontology, for which she serves as the professional development manager.×
Article Information
Special Populations / Cultural & Linguistic Diversity / Older Adults & Aging / Healthcare Settings / Practice Management / On the Pulse
On the Pulse   |   March 01, 2017
SNF ‘Rules’: True or False?
The ASHA Leader, March 2017, Vol. 22, 32-34. doi:10.1044/leader.OTP.22032017.32
The ASHA Leader, March 2017, Vol. 22, 32-34. doi:10.1044/leader.OTP.22032017.32
Working in skilled nursing facilities (SNFs) can be rewarding, but challenging—and one of those challenges is understanding Medicare rules. Some SNFs ask clinicians to adhere to Medicare “rules” that are not, in fact, rules.
The misinformation can affect patient care, undermine clinicians’ judgment, and confuse even the most seasoned speech-language pathologists. Let’s look at some of the most widespread myths and how SLPs can respond to them.
Misconception #1: Evaluations should be limited to 15 minutes.
“All of my evaluations are scheduled for 15 minutes and I am told to bill the rest of the time as treatment. I am having a hard time collecting all of my baseline data. Do you have any advice?”
Fact: The amount of time billed for evaluations should equal the amount of time a skilled rehab therapist spends completing the evaluation. The evaluation should capture the essential baseline data and clinical information needed to fulfill documentation for plan of care requirements per the Medicare Benefit Policy Manual (Chapter 15, Section 220).
Therefore, SLPs should keep open lines of communication with their rehab directors to ensure daily schedules include ample time for assessments. Evaluation time should never be billed as treatment time.
Misconception #2: Time for documentation that is not face-to-face is included in all evaluation codes.
“I complete my evaluation documentation in the afternoon after patient care and count the time in the evaluation CPT (Current Procedural Terminology) code. How much time can I bill for documentation?”
Fact: The evaluation codes 92521 (evaluation of speech fluency), 92522 (evaluation of speech sound production), 92523 (evaluation of speech sound production with evaluation of language comprehension and expression), 92524 (behavioral and qualitative analysis of voice and resonance), and 92610 (evaluation of oral and pharyngeal swallowing function) are untimed. Time spent on non-face-to-face documentation cannot be accounted for separately for untimed codes because documentation time is already factored into the value.
There are also four per-hour, time-based codes—96105 (assessment of aphasia), 96125 (standardized cognitive performance testing), 92607 (evaluation for prescription for speech-generating augmentative and alternative communication device), and 92626 (evaluation of auditory rehab status)—with a recommended 31-minute minimum for reporting the first hour, and a 91-minute minimum when reporting the second hour. SLPs may count documentation time toward the minimum minutes only when billing for 96105 and 96125, and only for Medicare Part B patients.
Therefore, SLPs can complete point-of-care, face-to-face documentation during the assessment with all evaluation codes. They can allot time outside of the evaluation for documentation and interpretation of standardized testing for 96105 and 96125, but only for Medicare Part B patients.
Misconception #3: Speech-language evaluations are required for IMPACT (Improving Medicare Post-Acute Care Transformation) Act, Section GG (Functional Abilities and Goals) data collection.
“My MDS (Minimum Data Set) coordinator is directing all rehab clinicians to evaluate all Medicare A patients in order to give her the data for Section GG. Can I justify an evaluation for ‘eating’ in my language patients?”
Fact: The implementation of Section GG does not change the evaluation regulations for skilled rehab care.
The IMPACT Act of 2014 requires standardized patient assessment data to enable data element uniformity, quality care and improved outcomes, comparison of quality and data across post-acute care (PAC) settings, improved discharge planning, exchangeability of data and coordinated care. (See the Policy Analysis column in the February issue.)
Data collection for skilled nursing facilities began in October of 2016. However, therapists should contribute to Section GG coding only if there is a skilled rehab need that aligns with the self-care and mobility subsets.
Therefore, if an SLP observes a skilled rehab need related to self-care, such as swallowing during eating, then they should actively engage in the evaluation with the interdisciplinary team. However, if there is no speech-language skilled care need, then other members of the team should code these areas.
Misconception #4: Diet changes can be completed only by an SLP.
“Mr. Jones lost his dentures … again. Nursing wants me to do an evaluation and three treatments to downgrade his diet while they are getting him a new pair.”
Fact: Diet changes due to functional impairments that are not directly related to the SLP’s scope of practice can be addressed by nursing under the direction of an attending physician. For example, changes in diet texture preference or oral intake changes related to dentures—where there is no diagnosed dysphagia—do not require an SLP to evaluate function or to provide dysphagia treatment.
Therefore, if a diet change is the result of something other than a swallowing difficulty, the order to change texture should come from a physician in response to nursing.
Misconception #5: Treatment time is set by the rehab manager.
“I printed my daily schedule from the electronic medical record and treated all of my patients based on what was scheduled by the rehab director. I am having trouble hitting all of my minutes. What should I do?”
Fact: Frequency, duration and daily intensity of care must follow evidence-based practice patterns and should be individualized to each patient’s needs as determined by the skilled therapist providing treatment.
Therefore, SLPs should collaborate with their rehab directors at the start of care and explain the therapeutic plan of care in addition to anticipated frequency, duration and intensity to promote patient-centered scheduling.
Misconception #6: Only occupational therapy (OT) can bill 97532 (development of cognitive skills), and SLPs should bill 92507 (treatment of speech, language, voice communication and/or auditory processing disorder).
“My company is telling me that I cannot bill 97532 (only OT can) and that I have to bill 92507 for my cognitive patients. They even took away my ability to enter the code in billing. What should I do?”
Fact: SLPs may bill either code. However, an NCCI (National Correct Coding Initiative) edit does not allow 97532 and 92507 to be billed together on the same day by the same provider for Part B Medicare patients.
92507 is a service-based code defined as “treatment of speech, language, voice, communication, and/or auditory processing disorder; individual.”
97532 is a time-based code defined as “development of cognitive skills to improve attention, memory, problem-solving (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes.” SLPs, OTs and psychologists are the primary billers of 97532 under Medicare Part B.
Therefore, SLPs should bill 97532 when the services they provide are reasonable and necessary and align with the code definition.
Misconception #7: CPT 92523 (evaluation of speech sound production with evaluation of language comprehension and expressions) must be billed prior to 96125 (cognitive performance testing).
“I have been told that 92523 is a ‘general overview’ code and that I should use it the first day while I am getting to know the patient. Then, after a week of treatment, I should bill 96125 for a more comprehensive assessment of status with the minutes counting on the MDS.”
Fact: No rules require sequential ordering of codes.
For Medicare Part A patients, the time spent on initial evaluation is not entered in the MDS or counted as treatment minutes because evaluation time is built into the facility’s reimbursement for the patient. Re-evaluations that meet certain criteria as defined by the Medicare Benefit Policy Manual do count toward the MDS. However, because 92523 and 96125 are two separate and distinct services, completion of one evaluation following the other is not a re-evaluation.
Therefore, therapists should select the appropriate evaluation type based on the individual patient’s needs.
Misconception #8: When an SLP provides care to a patient, the care is considered skilled.
“If I am seeing a patient the care is skilled. Right?”
Fact: Services that do not require the performance or supervision of a clinician are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional.
Therefore, documentation of your services must indicate the need for skilled care to qualify for Medicare reimbursement.
Misconception #9: Skilled care is determined by diagnosis alone.
“Our medical director will not allow any rehab for patients with progressive neurological conditions due to diagnosis. Should I just screen these patients?”
Fact: Although a beneficiary’s particular medical condition is one factor in deciding if skilled therapy services are needed, a beneficiary’s diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of an SLP are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel.
Skilled rehabilitative care that maintains function or prevents functional decline is covered under Medicare. Therefore, denying rehab services merely because there is no expectation of improvement is against Medicare regulations.
Misconception #10: Patients may not receive speech-language treatment if they are not receiving other skilled-care services.
“Physical and occupational therapy have discharged a patient. Now I’m told I have to discharge the patient, too, because speech alone is not considered skilled care.”
Fact: There is no regulation that indicates SLPs cannot provide skilled care as a stand-alone discipline. Therefore, the patient’s need for occupational or physical therapy is irrelevant if the patient needs speech-language treatment.
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March 2017
Volume 22, Issue 3