Clinical Café Newsletter
By: Ronda Polansky M.S. CCC-SLP
Happy St. Patrick’s Day
“May your blessings outnumber the shamrocks that grow
and may trouble avoid you wherever you go
may your right hand always be stretched out in friendship
and never in want.”
TSHA is coming to San Antonio this month! – This year it is March 8th-10th. Pam and I will be presenting this year at TSHA: “What you cannot see at bedside.” Russ Campbell, Rick McAdoo and I will be giving a short presentation regarding E-stim. Hope to see you there!!
UPCOMING 8 hr E-STIM ASHA CEU course – in Bedford, Texas on Saturday March 24th! See enclosed information to register. I hope to do another dysphagia CEU course forReliantHospital in the spring and 1 in the summer; look for upcoming details.
A Legal Implications of Clinical Documentation course is in the planning phase for April or May… be watching for more information.
TSHA vs. ASHA CEUs – This is one of the most often asked questions and one of the most misunderstood CEU issues. TSHA is an approved sponsor for SLP CEUs in the state of Texas, as well as an ASHA approved CE provider. TSHA and ASHA have a reciprocating agreement, in that they recognize each other’s program of approved hours. You can attend a TSHA approved CEU and receive credit for CE hours that will go towards renewing your license as well as maintenance of your ASHA CCC. ASHA uses “CEU” (1 CEU is equal to 10 TSHA hours) while TSHA uses “hours.” TSHA hours can count towards ASHA requirements and your CCC, and ASHA hours can count towards Texas licensure requirements. ASHA requires 30 hours (3.0 CEUs) every 3 years to renew the Certificate of Clinical Competence (CCC). TSHA hours do not count towards the ASHA ACE award. If you are working to earn ASHA’s Award for Continuing Education Excellence (ACE), then you must list all of your CE hours with ASHA. If you are a TSHA member, TSHA maintains a CE registry that lists only TSHA approved courses. The TSHA registry is free to any TSHA member. You don’t have to submit anything in this case, because when TSHA receives the registration roster (your TSHA number is on the roster), it is automatically loaded to the TSHA registry. ASHA maintains the CE registry that lists only ASHA approved courses. If you are paying extra to ASHA to be on their registry, then submit to ASHA. If you are not a member of either organization, then you need to hang onto your verification form in case you are audited. CE units/hours cannot be posted to both the TSHA and ASHA CE registries. The Texas State Board of Examiners for Speech Language Pathology and Audiology requires 20 hours in 2 years, with 2 of those hours being in ethics. ASHA requires all certificate holders to accumulate 30 certification maintenance hours every 3 years to maintain their CCC. TSHA itself does not require any hours to maintain membership. When you are audited by the board for proof of CEUs, you can print a TSHA registry transcript (free to members), or your ASHA registry ($24.00 per year) and send it to the Licensure Board. When you are audited by ASHA for your CCC renewal, you print your TSHA CE registry transcript and send to ASHA. If your hours are listed on the ASHA registry, you do nothing. ASHA can look at the registry and know how many hours you have earned. I hope this answers some questions and clears some confusion. If you need further information or would like to follow up on your CE course registry, please contact
- ASHA CE contact Loretta Lee at Loretta@leeresource.com
- TSHA CE contact – Karen King at email@example.com
- TSHA CE processing – Tammy Ybarra at firstname.lastname@example.org
- For questions about state licensure or the jurisprudence exam contact the State Board of Examiners at email@example.com
Is the patient appropriate for an MBSS?
We have had several instances lately where we have had inappropriate patients on the mobile clinic for an MBSS. In fact, some of the first words of the treating SLP upon entrance to the van have been that “this patient isn’t really appropriate.” Some of our SLPs (including me), have been subject to being hit, kicked, bitten (with lasting effects), spit on, vomited on, and/or patients requiring immediate suctioning due to vomiting or inability to manipulate the bolus orally. This is why a bedside swallow evaluation is completed… to determine appropriateness for further instrumental assessment. Although we do many, many MBSSs and are extremely well-versed on a large variety of patients, diagnoses, and behaviors, it does not make the situation any more appropriate if the patient is inappropriate.
Not only is it unethical to order an MBSS on an inappropriate patient, but Medicare sees it as fraudulent because there is lack of medical necessity. You can also refer to the ASHA website and the Dysphagia Instrumental Assessment.
Attempting MBSS on these types of patients can create a liability issue for us as the company providing the service on a high-risk patient or a patient that is not appropriate. If family is requesting at study for a patient that does not meet the necessary requirements for an MBSS then Medicare will likely deny coverage and they may have to pay “out of pocket.” Patient safety always comes first!! No matter how much nursing, the DOR, or the administrator, etc. wants a study completed, the risk of frank aspiration on a medically unstable patient is inappropriate. Note the following as a list of indicators that may signify your pt is inappropriate for a MBSS:
- medically unstable
- agitated or physically aggressive with possibility of harming the therapist or themselves
- unable to manage their own secretions and saliva (If they cannot do this, they will be unable to manage a bolus adequately or its residues.)
- unable to trigger a swallow reflex on command or reflexively
- not alert, lethargic (This is key to a functional swallowing assessment and safePOfeeding!)
- poor sitting position for study and for feeding (If we cannot see the VC or posterior wall of vestibule, we will not complete the study, because it will not be accurate and efficient.)
- nausea and vomiting within the last 24 hours, with or without fever
- unable to acceptPOfeeding by mouth due to oral defensiveness, bite reflex, apraxia, inadequate bilabial closure, lethargy, etc.
If you truly believe the patient is aspirating when you assess them, making an NPO recommendation at bedside can be appropriate. If we determine the patient to be inappropriate for the study after we arrive, the facility will still be required to pay a cancellation fee (as stated in our service agreement). We appreciate your team effort on this with us.
“My patient does better in the AM”
People eat morning, noon, night… and in between. It is not always the best idea to do the MBSS study at a patient’s most optimal time. You want to see them at their worst time, too. If the patient is in rehab and tired at the end of the day, wouldn’t you like to know if dysphagia is worse at the end of the day and they are having more difficulty with afternoon or evening meals?? Do not limit your patient’s evaluation to time of day. It is not really a complete evaluation and adequate assessment of their ability if you do their study only when they are rested and fresh!
Medical necessity required for an MBSS and every repeat MBSS
With new healthcare changes and new Medicare changes and new codes in our future, Medicare is requiring more and more from service providers and in documentation as a Medicare provider. Medicare will no longer accept reasons such as 1) the patient wants to eat, 2) the family wants the patient to eat, 3) the patient is eating AMA, etc. There must be medical necessity. Medical necessity includes change in status (which can be a decline, improvement, or new diagnosis). This needs to be clearly stated on your paperwork sent to us for the referral. We do not have access to your patient’s chart until the day of the study, so we cannot determine patient status unless you provide that to us. Make sure your paperwork required for the MBSS states the medical necessity for the initial MBSS AND for every repeat study! If we do not have this information, we cannot schedule the patient. The history/consult form is a part of the medical record for us and for the patient, so please fill out ALL of the information requested! Thank you for your help with this.
Results of 2011 Annual Survey for Speech Pathologists – by Jason Moshie in ADVANCE
Between June and November of 2011, 1,575 SLPs took a salary survey. The majority of SLP respondents (22.5%) reported earning between $50,001 to $70,000. 17.2% reported earning between $40,001 and $50,000. From $70,001 and $80,000 was the range for 15.8% of SLPs. Eight percent (8%) report incomes of $80,001 to $90,000; 4.92% earn between $90,001 and $100,000 and 2.49% take in over $100,000. A little more than 3% make less than $30,000 a year. More than 57% of the respondents work overtime in a 5 day work week, but only 18.7% were compensated for that extra time. More than three-quarters take work home with them. The majority (55%) responded they were “somewhat satisfied” with their job and a third said they were “very satisfied.” Bonuses in the field were rare with only 14.9% of SLPs indicating they received one.
Dysphagia Tidbit – xerostomia, dysphagia, and treatment – Xerostomia is a reduction in saliva, affecting 1 in every 4.5 people. It can be caused by medications, a disease process, reduced blood flow, and aging. Diagnoses that commonly present with xerostomia include Sjogrens syndrome, laryngoesophageal reflux, HIV, GERD, and cancer. There are also many contributing drying agents that increase this problem including tobacco, alcohol, caffeine, C-PAP machines, and mouth breathing. Xerostomia can reduce a patient’s ability to chew; chewing can become painful without adequate saliva. Xerostomia reduces the ability to propel solids and pills through the oral and pharyngeal phase; it changes taste, reduces oral sensitivity to temperature, causes tooth decay, increases risk of thrush, and of course creates obvious bad breath issues.
Education on the following may help in alleviating some of the issues: drink plenty of water (if safe on thin liquids), change any medications if possible, avoid alcohol, stay away from sugary foods, avoid dry foods, use a humidifier, chew sugar-free gum (which stimulates both sympathetic and parasympathetic glands), suck on hard candy (not mints), use saliva-producing medications and oral rinses, and treat any GER or LPR. An E-stim study completed in the Journal of LA State Medical Society in Jan-Feb 2010 showed E-stim of post-irradiated head and neck squamous cell carcinoma improved xerostomia.