3 Factors to Consider When Evaluating SNF Speech Therapy Service

Historically, Speech Therapy has jokingly been referred to as the “red headed step-child” of rehab.  My apologies to our friends who just happen to have red hair. With the advent of PDPM and the new role of Speech, Owners and Operators of Skilled Nursing Facilities are evaluating their speech therapy delivery.  In order to do so properly, let’s ponder these important aspects:

1. Case Load – What is a typical case load for a speech therapist?  You’d be surprised how many owners and operators never considered this question.  Maybe because finding speech is often challenging, they were happy just to have someone to care for the speech needs of the patients. SNFs now need expert insight over:

  • Typical speech case load
  • Distribution of patient conditions on case load (dysphagia, speech language deficits, cognitive impairment)
  • Duration of treatment for both short-term and long-term patients

2. Part B / Case Mix – Does Speech generating Part B revenue on a monthly basis for your SNF?  A great speech department should excel in caring for the long-term care population. Therefore, they should generate Part B revenue and for those in case mix states, make a meaningful contribution to CMI. 

3. Backup and Coverage –   What happens when your “regular” SLP is sick, on leave, or on vacation?  Is it difficult to arrange coverage? Is it a royal pain? If you are lucky enough to have an SLP to help cover, is that person productive, efficient, and passionate about treating in a medical setting?  Bringing in a temp or a traveler can fill a need, but at a hefty price tag.

Want to take a deeper dive into these issues related to your SNF?  We here at Language Fundamentals offer a Speech Department Utilization Analysis and would be glad to perform one for you.  We’d be glad to help.

Message me directly or contact us in the comment box below.

Food (and Reimbursement) on the Table Under PDPM

The implementation of PDPM in October is fast approaching and as we await the proposed rule, skilled nursing facility owners and operators are diligently preparing.  One interesting bit of datum that I have been following closely surrounds the complexity of reimbursements associated with altered diets & swallowing problems in the SLP (Speech) Component.

Just to recap, under the Patient Driven Payment Model the newly developed SLP component has 12 distinct levels of reimbursement (see below).  These levels are the result of answering five questions, and these questions are grouped into two separate (and differently weighted) groups.  The second group has much more to do with eating chewing and swallowing. 

The SLP Component Under PDPM

Group One:

1. Does patient’s primary diagnosis fall under acute neurologic or non-neurologic?

2. Is there an SLP related comorbidity?

3. Is there a moderate to severe cognitive impairment?   

Group Two:

4. Is there a swallowing disorder? 

5. Is the resident on an altered diet?

The answer to these questions will place the resident into one of 12 categories, SA-SL.  If you guessed the “S” stands for super, you would be right. (Yes, it stands for speech but give that one to us)!

My main emphasis for this article is to demonstrate the importance of evaluating new residents for appropriate diets.  Let’s illustrate with two different examples:

Resident A is medical management (non-neurologic) with no speech co-morbidities, is cognitively intact, has no swallowing issues, and is on a regular diet.  Resident A will fall into the SA category.  A SNF in Long Island, NY for example will receive $18.12 per day in the SLP category for each day of the Med A stay.

Resident B, on the other hand, is evaluated by a highly qualified SLP who can clearly document a swallowing dysfunction and consequently the need for an altered diet to ensure safe PO intake. Resident B will then fall into the SC category and the facility will receive $70.86 per day in the SLP category for each day of the Med A stay. A difference of $52.74 per day. 

Over the course of that 30 day stay, the difference of $1,582.20 is significant.  The difference between a highly skilled speech department and one that is less that proficient could be “make or break” under the PDPM.

In the next few months, we will focus on ensuring residents are getting the best care possible from speech. We will also discuss accuracy of coding & the importance of strong supportive documentation. The importance of having coding & documentation that can survive future audits must not be forgotten in the PDPM transition.

Want to dive deeper on the Speech Component? Do you have ideas or questions? I’d love to talk. Please feel free to comment in the box below.

Sights and Sounds from the NY ACHCA Convention

Language Fundamentals had the pleasure of participating in the 50th New York Chapter ACHCA convention this week at its new venue, the Resort World Catskill.

Since the FY 2019 CMS Final Rule has been finalized, it means the Patient Driven Payment Model (PDPM) is coming and SNF stakeholders must now adapt. Attending events like this one allow us the unique opportunity to both attend educational sessions and gain the perspective of the attendees during networking. Here’s some of what we observed:

1. PDPM – SNF providers are accepting the fact that PDPM is coming in October 2019 and are now getting ready.  I wouldn’t just look at a numerical analysis of how your RUG scores would translate into PDPM. I recommend having a trained clinical expert guide your SNF through the transition to PDPM.

2. Speech Therapy – SNF Operators need to look very closely at the Speech Department.  There’s a great deal of reimbursement on the line in the SLP category under PDPM and the cost of doing it wrong will be significant. Consider utilizing a speech expert, like Language Fundamentals, to do a Speech Department analysis.  We’d be glad to help.

3. State Budget – March is always the month of State budget crunches. Medicaid dollars are at stake and associations like NYSHFA are fighting hard on behalf of the members.  Changes to Medicaid CMI are putting even more stress on the system

4. Telemedicine – Industry stakeholders support increasing access to telepractice to provide services, especially for patients with complex needs. However, there is a feeling that the technology is there, the regulations are an obstacle. 

Lots of exciting stuff.  We’d love to hear your thoughts in the comment box below.

Would you like to talk about how Language Fundamentals can provide the best Speech Therapy available to your SNF?  Let’s talk.

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:http://dx.doi.org.jerome.stjohns.edu:81/10.1007/s00455-016-9696-8

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