Medical Diagnosis vs. Treatment Diagnosis – The Guide to Getting it Right in the SNF

Selecting accurate medical and treatment diagnosis codes are incredibly important when evaluating and documenting a plan of care for patients in the SNF setting; both for billing purposes, as well as accurately developing a patient’s profile and course of treatment. The evaluating therapist must document the correct codes, and should understand how they interact.  

First, let’s consider the difference between a medical and a treatment diagnosis.

Medical diagnosis:

  • Determined by a medical professional such as a physician or nurse practitioner
  • Identifies a disease or a medical condition
  • Provides information about the patient’s pathology

Treatment Diagnosis:

  • Selected by the evaluating PT, OT, or ST
  • Represents the patient’s functional limitation as a result of the disease or medical condition
  • Should identify the signs, symptoms, and/or conditions that the therapeutic intervention is treating

Now let’s look at an example of a medical diagnosis vs a treatment diagnosis, and how they interact.

Patient X is admitted to a SNF after an acute hospital stay following a L MCA stroke.

The medical diagnosis would have been determined by the MD in the hospital:
I63.412 Cerebral infarction due to embolism of left middle cerebral artery.

When that patient is evaluated by the Speech Language Pathologist in the SNF setting, they may identify numerous functional deficits as a result of the medical diagnosis of I63.412.

The treatment diagnosis may consist of:
 I69.320 Aphasia following cerebral infarction
I69.322 Dysarthria following cerebral infarction
I69.391 Dysphagia following cerebral infarction

Jennifer Maher, MA, CCC-SLP is a treating Speech Language Pathologist with Language Fundamentals in New York, New York.

In this case, the medical diagnosis (CVA) identifies the pathology, and all three treatment diagnoses (aphasia, dysarthria, and dysphagia) are complimentary diagnosis that indicate the functional change that occurred as a result of the patient’s stroke and will be targeted during the therapeutic intervention. Having an accurate medical and treatment diagnosis will provide the therapist with a clear picture of what they are treating and why.

I hope this article is helpful in providing some clarity. Have any thoughts or questions? I’d love to hear. Feel free to comment in the box below.

About the Author:

Originally from Port Jefferson, New York, Jennifer Baquet Maher, MA, CCC-SLP has a Masters Degree from St. John’s University Communication Sciences and Disorders program.   Jennifer and her husband, Noel, recently welcomed their daughter Ella Josephine to the world on August 3, 2018.  In her spare time, Jen also enjoys cooking and traveling.

Is There a Right Way to Overhaul Medicaid Reimbursement for SNFs?

The early part of each calendar year is synonymous with state budget battles, where projected Medicaid cuts to Skilled Nursing Facilities always seem to be a hot button issue.

On one hand, Skilled Nursing Providers are already paid far below cost in virtually every State.  On the other hand, individual states want to reduce Medicaid expenditures and nursing homes seem to be in the cross-hairs every year.

Where does it end?

Some States, like Connecticut, have historically reimbursed SNFs based on cost.  The aggregate clinical acuities of the patients, or case-mix, has no bearing on the daily reimbursement to the facility.  Connecticut has seen a significant number of nursing home closures in recent years, and operators are at their wits end.

More than half of the States utilize various case-mix methodologies to compute daily reimbursement.  On the surface, it makes sense to reimburse the facility based on the acuity of the patients (i.e. sicker the patients – > the more resources needed -> the more reimbursement the facility receives).  However, states like New York are objecting to the increases in overall Case Mix Index (CMI) in recent years.  Meanwhile, New York nursing homes face a $60+ per patient per day Medicaid shortfall based on 2017 statistics.

Is there a system out there that would satisfy all the stakeholders by containing costs for the States and reimbursing SNFs fairly for caring for the frail and elderly?  Will the PDPM system help or hurt SNFs when it comes to Medicaid shortfalls?

In an upcoming edition of the Language Fundamentals blog, we will dive deeper into this issue.

In the mean time, please share your thoughts or questions below.

Coding Speech Related Comorbidities Under PDPM

Patient-Driven Payment Model (PDPM), is fast approaching with implementation set for October 2019.  With several big changes ahead and the margin for error slim for most providers, preparedness will be the key to a smooth transition.

As many are already aware, reimbursement under PDPM will be shifted from the number of therapy minutes, to the clinical characteristics of the resident.  Accurate diagnosis coding on the 5 day MDS will be a primary driver, and Speech Language Pathology services will provide a vital role in reimbursement.  

Today, we have a generation of therapists and clinicians that never had to become adept at diagnosis coding in order to perform their jobs.  Clinicians can typically go through graduate and post graduate work without ever learning the difference between ICD-10 codes and many have difficulty with the concept of having a primary diagnosis and a treatment diagnosis.  

Speech Therapists in the SNF will need to identify the presence or absence of one or more of the following comorbidities or treatment diagnoses.

Let’s take a minute to review how proper treatment diagnosis coding will affect speech reimbursement:

SLP-Related Comorbidities
MDS Item
I4300 Aphasia*
I4500 CVA, TIA, or Stroke
I4900 Hemiplegia or Hemiparesis
I5500 Traumatic Brain Injury
I8000 Laryngeal Cancer
I8000 Apraxia*
I8000 Dysphagia*
I8000 ALS
I8000 Oral Cancers
I8000 Speech and Language Deficits*
O0100E2 Tracheostomy Care While a Resident
O0100F2 Ventilator or Respirator While a Resident

The treatment diagnosis that are denoted with the * will need to be identified by a trained Speech Language Pathologist. The SLP will then need to have the skill set to identify the condition, describe the extent, outline the proper plan of care, and provide supportive documentation. 

Accurately coding all of the appropriate SLP related comorbidities, will help the interdisciplinary team understand the needs of the resident, but also positively impact level of reimbursement.  Depending of geographic area, proper coding of move a resident from “SA” ($16.45) to “SD” ($35.32) and this is just one area that speech will impact reimbursement under PDPM!

This example is at the heart of PDPM, reimbursing the SNF based on the clinical condition of the patient, not the number of minutes provided.

The bottom line:  SNFs will need to quickly and accurately identify treatment diagnosis/comorbidities to ensure that they are seeing accurate & appropriate reimbursement.  The supportive documentation also needs to be in place to ensure payments will stand up to audit.

If you have any questions or thoughts, please feel free to comment in the box below. Need help with Speech Therapy at your SNF? Give us a call, we’d be glad to help.

Not All Thickened Liquids are Created Equal

Dysphagia is an impairment in that effects the normal swallowing process secondary to a neurological or structural problems.  Often times, this means a person is unable to safely and/or efficiently eat or drink.

 Statistics from the American Speech and Hearing Association on who is affected by dysphagia:

•           22% in adults over 50 years of age

•           Up to 68% for residents in long-term care settings

•           CVA:  >50%

•           TBI: 26-71%

•           Parkinson’s disease: 50-92%

•           ALS: 100%

•           Dementia: most common in moderate-severe impairment levels

 Approximately one third of patients with dysphagia develop a serious condition known as aspiration pneumonia and 60,000 individuals die each year from such complications.

Speech Language Pathologists (SLPs) know these statistics well and are trained to diagnose and treat dysphagia. An important part of the SLPs treatment may include diet modification to either the texture of a person’s food, or viscosity of the liquids they drink.

Jennifer Maher, MA CCC-SLP of Language Fundamentals

The SLP may recommend thickening liquids to either a nectar or honey consistency in order to decrease the risk of aspiration, however, this does not come without its own challenges. Making a recommendation to provide only thickened liquids raises concerns of noncompliance, dehydration, malnutrition, and overall impact on a person’s quality of life.

According to the European Society for Swallowing Disorders in 2016 “there is evidence for increasing viscosity to reduce the risk of airway invasion and that is a valid management strategy for OD. However, new thickening agents should be developed to avoid the negative effects of increasing viscosity on residue, palatability, and treatment compliance.”¹

Historically, all thickened liquids used with a starch agent because it was inexpensive and readily available. While this is still true, starch comes with significant limitations:

  •    Not stable and may continue to thicken the drink over time
  •    Has a “gritty” texture
  •    Can have a cloudy appearance to the drink
  •    May increase pharyngeal residue and be more difficult to clear if aspirated.

 Recently, an update of the science of thickening agents have provided a solution to many of the issues related to thickened liquids. Xanthan based thickeners have provided a starch alternative that can significantly improve safety and quality of life.

  • Does not continue to thicken over time
  • There is no change the way the drink looks (water remains clear)
  • The taste of the drink remains the same without having a gritty qualit
  • It is suggested that there is less risk of pharyngeal residue and may be easier to clear if aspirated.

 It is important for speech language pathologists, caregivers, and patients managing dysphagia to learn about the options when choosing thickened liquids, because clearly, not all thickening agents are created equal.

Would you like to talk more about speech therapy, thickened liquids, or more?  I’d love to hear your thoughts.  Please use the comment box below. 

About the Author:

Originally from Port Jefferson, New York, Jennifer Baquet Maher, MA, CCC-SLP has a Masters Degree from St. John’s University Communication Sciences and Disorders program.   Jennifer and her husband, Noel, recently welcomed their daughter Ella Josephine to the world on August 3, 2018.  In her spare time, Jen also enjoys cooking and traveling.


1- Newman, R., Vilardell, N., Clavé, P., & Speyer, R. (2016). Effect of bolus viscosity on the safety and efficacy of swallowing and the kinematics of the swallow response in patients with oropharyngeal dysphagia: White paper by the european society for swallowing disorders (ESSD). Dysphagia, 31(2), 232-249. doi:

4 Important PDPM Issues Related to Billing

Over the years, anytime a significant regulatory change has occurred in the SNF industry, the software solutions providers have sprung into action to ensure the functionality is in place for their customers.  These software solutions providers are used to dealing with annual changes associated with the MDS & always having these updates running by October 1st, which coincides with the beginning of the Medicare fiscal year.

The Patient Driven Payment Model, (PDPM) is targeted for October 1, 2019, and is the most significant change to reimbursement we have seen since MDS 3.0.   Today we look at 4 PDPM issues related to billing that, when speaking with your software solutions providers, will help SNF operators ensure preparedness and implement any new workflows.

 1. Ready for the “Hard Switch?”  – On a recent Medicare Learning Network call, CMS officials advised the audience that there would be no transition period from RUG IV to PDPM.  Instead, the “hard switch” will occur on 10/1/2019.  RUG-IV rules will be in effect until 9/30/2019.  PDPM rules on 10/1/2019. MDS Coordinators will need to lead the charge to ensure accuracy and compliance when it comes to MDS Assessments.

2. What about Medicare Advantage?  – Medicare Advantage plans typically reimburse SNFs according to either a RUG score or Level of Care.  CMS will continue to leave this up to the individual payors, thus increasing the level of complexity for the providers.  Operators should proactively engage the individual Medicare Advantage plans and discuss their PDPM transition plan.  From a software perspective, the providers will need to ensure the setup of the payors in the back end of the billing system will allow for the continued production of clean claims.

3.  How about PDPM scores? – Under the current RUG-IV system, the coding of the MDS for Medicare patients produces one of 66 RUG categories for billing.  Starting 10/1/2019, a PDPM HIPPS code will be produced. Engage your billing team early, and run parallel so there are no surprises, especially with tight cash flow margins.

 4. What about the LTC population? – Recently CMS announced that on October 1, 2020, they will no longer support RUG-III and RUG-IV case-mix methodologies, which are used by many states for Medicaid CMI.   CMS has recently announced that they have created an optional state assessment (OSA) to use during Fiscal Year 2019.  If you are in a Case Mix state, it is critical that your software provider can support you through this change.

 Exciting stuff!  I’m sure there’s so much more to cover, & hopefully I helped you get the ball rolling.  If you’d like to share some thoughts, please use the comment box below. 

Cognitive Communicative Deficits & The Role of The Speech Language Pathologist

A Cognitive Communicative Deficit is defined as an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness.

As Skilled Nursing Facilities around the country are treating more medically complex patients, along with these chronic conditions can come cognitive communicative deficits.  Speech Language Pathologists can be a tremendous resource and provide valuable insight into the overall clinical picture of the patient.

According to ASHA, some of the most common etiologies related to cognitive communicative deficits include:

·       Alzheimer’s Disease

·       Dementia

·       Brain Tumors

·       Stroke

·       Traumatic Brain Injury (TBI)

The potential consequences of Cognitive Communicative Impairment can be significant.  They include:

·       Reduced awareness/ ability to initiate and effectively communicate needs

·       Reduced awareness of impairment and its degree (i.e., loss of ability to assess one’s own communication effectiveness)

·       Reduced memory, judgment, and ability to initiate and effectively exchange routine information

·       Difficulty performing personal lifestyle management activities effectively (i.e., pay bills)

·       Reduced ability to anticipate potential consequences, with reasonable judgment and problem solving

·       Reduced social communication skills and/or ability to manage emotions, often causing loss of relationships

·       Disruption of ability to fulfill educational or vocational roles, including potential loss of employment

·       At risk for injury due to inability to communicate in an emergency and/or anticipate the consequences of own actions

Jaclyn A. Gregg, MS, CCC-SLP is the Regional Manager for the Albany, NY region of Language Fundamentals, Inc.

Did you know that Speech Language Therapists are valuable assets in treating Cognitive Communicative Deficits? 

1.  SLPs are trained to look for CHANGES.  Changes in environment, routine, orientation, or staff can negatively affect the residents’ ability to communicate.

2. SLPs review QUALITATIVE DATA such as nursing documentation for pieces of valuable information related to communication such as family / staff interviews, behaviors, safety during ADLs, Prior Level of Function and discharge plan

3. SLPs utilize QUANTITATIVE DATA including structured evaluation/screening tools (MMSE, MOCA/ MOCA-B, BCRS, SLUMS, Observation Checklists, etc.)  These tools are used to make informed interpretations/implications in regard to resident function.

Organizations who provide Speech Therapy for Skilled Nursing Facilities will need to hone their cognitive therapy skills in anticipation of PDPM.

At the SNF setting consider a referral to speech therapy for changes in:

·       Mood (e.g., increased frustration)

·       Communication ability

·       Ability to participate in ADLs

·       Orientation

·       PO intake

 Have any thoughts or questions?  I’d love to hear!  There’s a comment box below for you to use

About the Author: Originally from Everett, Massachusetts, Jaclyn Gregg, MS, CCC-SLP is a graduate of the College of St. Rose Communication Sciences & Disorders Program.  Jaclyn, her husband Brad, and 6- month old daughter Tatum live in Upstate New York.  In her spare time, Jaclyn enjoys hot yoga and spending time with family.

4 Big Questions for the SNF industry-Wishing I Could Predict the Future

Recently when it comes to thinking about present state of the SNF industry, I’ve found myself thinking more about the upcoming year than ever before. This isn’t something I’ve always done during my 46 trips around the sun, so I am not sure why it is happening now. I guess its more common to look retrospectively and say “wow, look at how many things have changed in the past year,” rather than “these exciting things are going to happen during 2019.”

It would be easy to turn this conversation into one just about PDPM, but I find myself thinking about things at a more macro level. The questions I frequently ask myself are:

1. How much more pressure can the Medicaid payment system sustain before it breaks? Deficits in daily reimbursement in many states are nearing that point. It seems to be getting worse, not better.

2. How many of the 16,000 SNFs in America are truly equipped to care for the increasing number of medically complex patients?

3. Is the industry appropriately funded in order to survive, and will PDPM mean the beginning of the end for some who are just fighting to stay open? PDPM is being tabbed as budget neutral, but that really means there will be winners and losers.

4. If SNFs with a 1-star rating are unable to make the improvements they need to compete, how will they survive?

What about you? If you are an LTC professional, what do you ask yourself?  Will we know these answers a year from now?  Each of these questions are a discussion on its own and we just might do that to keep our brains working over the winter.  If we were to fast-forward one year, what would we see? In upcoming editions of our blog, we will be providing more insight into these questions.

If you’d like to share a comment or thought, scroll down to the comment field.  I’d love to hear your ideas

Combating the Effects of Dementia with 2 Out of the Box Ideas

In a recent article, we discussed direct therapy interventions to help stave off memory, cognitive and speech concerns associated with the early and mid-stages of dementia.  According to the World Health Organization (WHO) dementia is a global public health priority and has significant social and economic implications in terms of direct medical and social care costs, and the costs of informal care. In 2015, the total global societal cost of dementia was estimated to be US$ 818 billion, equivalent to 1.1% of global gross domestic product (GDP). With 7.7 million new cases identified each year, they estimate 65.7 million people expected to have the condition by 2030.   Beyond direct intervention there are several adaptive and environmental opportunities that we can take advantage of to prolong quality of life.  Since the list below is not exhaustive and there are several other things available, the role of this article is essentially to begin the dialogue.

External memory aids and Assistive technology: External memory aids are aimed at helping individuals with memory problems in their day-to-day activities. In fact, we use them every day and as technology increases, so does our dependence.  (When was the last time you remembered a phone number).  Smart phones and watches keep us on time and in touch with he world and with just a few words “Hey Siri/Alexa/Google” we can ask a device with a modicum of Artificial Intelligence (AI) to remind us to do something or be somewhere.  With a good internet connection, these devices can be used by family members and care givers to remind people with mild dementia to take their medications or even eat.  Some devices are already in use making environmental controls easier off site such as controlling lights and heating or air conditioning, but as they advance and get smarter, they may help us do more.  It is possible that these devices can check important safety features such as the stove temperature and ensure that the water hasn’t been left on, prolonging a person’s independence.

Environmental modifications: Environmental modifications are changes or adaptations to the environment to improve communication skills in individuals with dementia. As an SLP we work closely with our physical and occupational therapy colleagues to assess the environment.  The idea is to make modifications that are aimed to optimize the cognitive, visual, and auditory aspects of the environment.  This may include improving lighting, reducing glare, and reducing visual and auditory clutter.  The use of signs and simple graphics may be implemented to increase safety awareness and/or orientation (Brush, Sanford, Fleder, Bruce, & Calkins, 2011).

Again, this is just a jumping off point, a platform to start the conversation not end it.  As we all age, the thoughts and fears of dementia and memory loss become more prevalent.  Research brings new possibilities each day and it is important to stay current and elastic in how we treat individuals.

Let’s keep the conversation going.  I’d love for you to share your experience.  Please use the comment box below.


World Health Organization. Dementia: A Public Health Priority. World Health Organization, Geneva; 2012

 Brush, Jennifer & Sanford, Jon & Fleder, Hannah & Bruce, Carrie & Calkins, Margaret. (2011). Evaluating and Modifying the Communication Environment for People With Dementia. Perspectives on Gerontology. 16. 32. 10.1044/gero16.2.32.


What Does a Diagnosis of Alzheimer’s Dementia Mean for Sandra Day O’Connor?

Alzheimer’s is the disease that keeps on taking…

It has been reported that Sandra Day O’Connor, the first woman on the Supreme Court, is in the beginning stages of dementia, possibly Alzheimer’s disease.  This is a devastating diagnosis for anyone to hear.  Alzheimer’s disease is a type of dementia that targets brain cells.  Dementia is progressive as the disease attacks more and more brain cells; effecting memory first and progressively effecting more of the body systems and may ultimately end with death.   As I heard this on the news, I was struck with sadness over this happening to such a brilliant legal mind.

Supreme Court Justice Sandra Day O’Connor

Treatment Options: As an Speech Language Pathologist, it is important to remember all treatment options, however not all options work for each individual and a proper evaluation is necessary to develop a treatment plan.  This list isn’t exhaustive and is focused primarily on ideas involving skilled therapy.  The goal of cognitive-communication treatment is to maximize the individual’s quality of life and communication success, using whichever approach or combination of approaches meets the needs and values of that individual.

Cognitive Stimulation Tx (CST): A group-based activity (typically small) that focuses on actively stimulating and engaging individuals with dementia by using theme-based activities.

Memory-training programs: These focus on improving/re-training memory skills using techniques such as spaced retrieval, error free learning, process memory stimulation and other learning strategies.

Reality Orientation (RO): This is a technique designed to reduce confusion and improve quality of life by providing orienting information (e.g., time, place, or person) to reinforce understanding and awareness of the environment. Information is repeated at regular intervals throughout the day.

Simulated presence therapy (SIMPRES): This is a little unique in that it is an emotion-oriented approach aimed at reducing levels of anxiety and challenging behaviors by playing audio recordings of the voices of close relatives of the individual. SIMPRES has been used to improve well-being (e.g., decrease agitation and withdrawal behaviors) in individuals with Alzheimer’s disease who have adequate hearing and have retained communication skills (Bayles et al., 2006).

In an upcoming edition, we will talk more about treatment options for Alzheimer’s dementia. Please feel free to share your thoughts in the comment box below.

The Shocking True Cost of Aspiration

As a speech language pathologist working with geriatric population my thoughts often turn to dysphagia and aspiration.  SLPs in skilled nursing facilities are always attempting to balance two distinct needs.  On one side we are attempting to provide residents the least restrictive diet while also ensuring safety and attempting to reduce the risk of aspiration.  Now, we spend so much time talking about aspiration and doing are best to ensure physicians, nurses, residents and families that, first, aspiration is a real thing and second that it has a real effect on the person’s health and the facilities bottom line.  Aspiration, particulates that fall below the level of the vocal chords, can lead to aspiration pneumonia, which can lead to re-hospitalizations and in severe cases death. 

Beyond the personal health risks associated with aspiration the are severe financial costs that impact families and facilities alike.  Pneumonia after stroke is associated with higher mortality and hospitalization costs. Patients with the highest risk for pneumonia also have the highest risk for death associated with pneumonia.  In a study published in 2012, Wilson noted that the average marginal cost of pneumonia on the hospitalization was $27,633 per episode and linked that an increased risk of acquiring aspiration pneumonia to an increased risk of death.  Backing up the claims of Wilson, van der Maarel-Wierink, Claar D. et al. (2011) noted that the risk of aspiration pneumonia is six times greater in patients over the age of 75 and mortality rates associated with aspiration pneumonia is about 5%

Mike Webb of Language Fundamentals and Mike Siacca of Zimmet Healthcare presenting at the 2018 National Association of State Veterans Homes Conference

So what does this mean?  Well, we are taking in more medically complex residents into our facilities each day, and this is a trend that will continue into the foreseeable future.  We also know that with the change to PDPM Speech will have a more significant role in reimbursement and the care of each and every resident.  Having a proficient, knowledgeable Speech Therapy Service Department that is able to reduce the risk of aspiration pneumonia and treat patients with dysphagia is imperative to reduce a facility’s hospital readmission rate, increase quality of care and mitigate risks to the resident and the facility.

If you have any questions, I’d love to hear your thoughts.  Please use the comment box below.