April 2012 Newsletter

Happy Spring & Happy Easter

Clinical Café Newsletter

By: Ronda Polansky M.S. CCC-SLP

Monthly Motivator:

April hath put a spirit of youth in everything.

—William Shakespeare

Upcoming CEU – Friday May 18, 2012  – Legal Implications of Clinical Documentation

6 TSHA CEU hours (please see March newsletter for explanation of TSHA and ASHA hours)

Only $30.00 ($5.00 per CEU credit) discounted rate for SLP’s using DiagnosTEX service.

Will be located inHurst,Texasfrom 9am to 4:30pm. Registration form will go out in May newsletter.

DiagnosTEX New Mobile Clinic Schedule starting in April. = Due to recent reimbursement rate cuts with Medicaid as well as insurance and the 92611 code etc.  We as a company have had to make some tough budget and scheduling decisions to maintain adequate coverage to meet demand as reimbursement declines.  We will no longer be running every Friday but will continue to offer outpatient services at our office in Hurst on that day. Our hours during the week will be a little longer as our last study will likely be scheduled around 4-5PM, instead of 3-4PM.  This helps us be more efficient in the geographical areas we are servicing on any particular day to get everyone scheduled with less days during the week.  We hope if funding improves we can again increase our days as needed.  With all this in mind, I again have to

re- emphasize, we will be less likely to accomodate ongoing requests for specific times of the day or specific days of the week efficiently.  If you patient or family has time constraints then your pending study may be delayed in scheduling or you may need to consider a free standing outpatient facility for their requested day and time.Mobileis for the convenience of us coming to the patient, and we can not meet everyone’s customized daily schedules and be efficient in the service we provide. We will be available for people to come to our office as an outpatient on Fridays if that is more convenient and we can be more flexible with times on that day.

Congress Passes Bill to Avoid 2012 Medicare Cuts – House and Senate Pass Bill to Avert Medicare Payment reduction and extend Therapy Cap Exceptions Process through 12/31/12. Congress added additional safeguards, including 1) the use of an NPI for the physician reviewing the need for therapy, 2) requirement for use of the KX modifier on claims above the cap, 3) requirement for medical manual review when therapy expenditures hit $3,700 (combined physical therapy/speech pathology) for several furnished on or after October 1, 2012. The bill will temporarily apply the therapy caps and exceptions to hospital outpatient departments for services provided no later than 10/1/12 and ending 12/31/12. Although the physician radiology codes were not reduced with the Congress passing the bill, the speech code for the MBS (92611) reimbursement was reduced again this year and now the evaluation is valued at less than $100. Insurance is paying about $300.00 less per study and Medicaid has stopped paying on higher Part B rates in certain counties.
New devices to be on market in 2012

The Cue- Minder – This is a compact cueing system designed to allow the clinician to use their own voice to provide reminders of correct behavior when they are not with the patient.  It is a small electronic device, powered by button batteries, and is based upon movement. For example, in dysphagia treatment a cue is provided by the tilting action of a cup.  It is a moisture resistant device that has a strap to fit onto any cup, plate, or utensil. The device is intended to use for more efficient carryover with movement toward generalization of desired behaviors. Prototype can be seen in test on YouTube for the key words “motion minder”, and should be completed later this year.

Expiratory Muscle Strength Trainer (EMST) – developed to help improve cough in patients with PD, which had an intriguing effect on swallow function too. It is a hand held device about the size of an inhaler that is a resistance trainer.  In research pre and post treatment indicated a decrease in penetration and aspiration scores and decreased the depth of penetration during the swallow and resulted in a more productive cough.

Aspiration prevention in tube feedings/NPO– Critically ill patients especially those who are tube fed, may experience small-volume, clinically silent aspiration which will increase risk of pneumonia.  Patients who are mechanically ventilated and tube fed are at 4x greater risk.  No BSE exist to detect micro aspiration, no matter how skilled you are.  New guidelines (ADVANCE 2012) have been issues to help standardize practice and update health care professionals to prevent aspiration, especially those items overlooked in those who are tube fed

1. Maintain HOB at 30-45 degrees, unless contraindicated
2. Assess patient every 4 hours for proper tube feeding placement
3. Assess gastric tube-fed patients every 54 hours for gastrointestinal intolerance
4. Avoid bolus feedings in tube-fed patients ay high risk of aspiration
5. Conduct swallow assessment beforePOstarts for a recently extubated patient.
6. A sustained supine position increases reflux and probability for aspiration

A study of 201 critically ill patients found that the distal tips of 24 of 116 feeding tubes originally positioned in a small bowel were displaced upward into the gastrointestional tract.  Administering feedings at the wrong site increases risk of aspiration. Bolus feedings may decrease lower esophageal pressure thus predisposing patient to reflux and aspiration.

Dysphagia Tidbit Images in clinical medicine New England Journal of Medicine

79 yo man evaluated for unintentional weight loss and dysphagia.  He received an MBSS at a hospital. During a rapid drinking phase, the patient aspirated a large amount of barium. (This is why we have a protocol! J).  Resulted in hypoxemia respiratory failure, intubation. Admitted to ICU, chest film shows both left right stem bronchi and segmental bronchi in LU and LL lobes. Barium was suctioned extensively, with treatment of inotropic agents and antibiotics, his condition still deteriorated. Circulatory shock developed, patient had severe anoxic brain injury after cardiac arrest and after family opted for conservative care, he passed away shortly thereafter.