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 Dallas Convention Center this month! – This year it is March 7th-9th. DiagnosTEX will be in booth 732. Please come by and see us! . Pam and I will also be presenting on Saturday at 10:45-11:45 in Room 101 on “Do you have X-ray Eyes? The Limitations to a Bedside Swallow Evaluation”.
AMPCARE, LLC will be behind us in booth 633
DRS – Dysphagia Research Society 21st Annual Meeting is March 13-16th in Seattle, Washington.
UPCOMING E-STIM ASHA CEU course – in Arlington, Texas on Saturday April 13th! Mark your calendar Registration for Arlington course included. There will be a course in Austin, April 27th. For more information call 682-561-2444.
FREE information session for Parkinson’s patients and their families IN Richardson, TX Parkinson Voice Project will continue hosting a free monthly information session for people with Parkinson disease and their families in 2013. The sessions will be presented by Parkinson Voice Project Founder and CEO Samantha Elandary, MA, CCC-SLP, and will consist of a lecture and video presentation about the basics of Parkinson’s and its effects on speech and swallowing. The lecture will take place on the 4th Tuesday of each month, excepting November, when it will be held the 3rd Tuesday due to the Thanksgiving holiday. No session will be held in December. Where: Parkinson Voice Project, 500 N. Coit Rd #2085, Richardson, TX 75080 How: Call (469) 375-6500 or visit http://pdinfosession.eventbrite.com
Salary Survey for 2012 by ADVANCE The survey was taken between June and December of 2012 on 1993 SLP’s.
- 84.14% work FT or more than 35 hours per week
- 54.6% earn between 50K-80K (same as last year), 19.22% earn between 60-70K, 15.35% earn between 70-80K.
- 26.24% have worked in the field more than 5 years with 15% working between 6-10 years.
- 41.14% work in the schools, 12.19% in LTC, 11.14% in private practice, >10% in HH
- 60% of hospital SLP earn between 50-80K, most popular setting for that salary range
- 32.32% earn less than 50K working with children, 27.02% if school based earned less than 50K
- 56.96% worked overtime over 40 hours and of those, over 800 SLP’s worked OT and OT was unpaid!
- 53.94% are somewhat satisfied with their jobs, 34.52% are very satisfied, and 62 people said “get me out!”
2013 Coding and Documentation for SLP’s – Reporting for Part B I have been taking many webinars from Novitas in 2013 and it certainly has been an interesting pastime! It is nothing that I did not know was coming, which is why I put on the Documentation CEU course last year! All documentation is usually reviewed by Medicare contract nurses rather than an SLP; therefore we should not assume that the reviewer will understand why the service requires the skill of an SLP. We not only have to justify therapy services with objective measures and must comply with Medicare policies but we have to list conditions and complexities. Where it is not obvious, we are required to describe the impact of those conditions and complexities on the prognosis and the plan of treatment. There must be justifications for continued treatment after regression and plateaus; this includes repeat evaluations such as an MBSS. Progress reports or re-evaluations must provide justification for the medical necessity!
Progress must be listed on the HX/consult form faxed into DiagnosTEX! Re-evaluations are ONLY reimbursable when there is change in the patient’s condition (good or bad). The treating SLP must have a documented assessment of improvement, extent of progress or lack thereof. A connection must be made between a medical condition and the swallowing disorder that is causing the medical condition. Each diagnosis listed should be related to dysphagia. (A-fib or HTN for example, is not one we can relate to swallowing).
Example of documented changes on HX form for repeat studies: decreased or increased timing of swallow, decreased/increased PO intake, increased/decreased management of saliva, increased or decreased coughing/choking with PO, increased/decreased strength, returned from hospital with diet change, Change in neurological status ( good or bad), etc.
Unacceptable reasons: AMA, want to see if anything has changed (no TX or TX gains), family request, doesn’t like diet recommendation/tired of thickened liquids, got pneumonia because they are eating against diet rec, wants to go home, family is bringing wrong food, doesn’t want PEG, likes coffee, refusing ST TX, won’t wear dentures, “Because” ( yes, we have gotten that).
Examples of swallowing goals Long term goal – Pt. to consume a mechanical soft diet with thin liquids without complications such as aspiration pneumonia,
Short term Goals:
- 1. Patient will improve Laryngeal elevation/timing of closure by using the supraglottic swallow on saliva swallows without cues on 90% of trails.
- 2. Patient will compensate for reduced laryngeal elevation by controlling bolus size to a ½ tsp. without cues 100% of time during meal.
The DiagnosTEX report will give you reasons for the disorder in the evaluation, such as reduced lingual control, reduced tongue base retraction, reduced laryngeal closure etc., as well as severity levels; use these for your progress notes and documentation for skilled service justification.
Example of documented progress – Tongue range of motion during oral prep has improved. Previously the tongue could not make contact with the teeth and cheeks. Now this skill is noted. The patient was unable to form a bolus because of reduced tongue range of motion and they were pocketing in the cheek area where there was risk of choking on food later if it fell into airway, increasing risk of aspiration. Now the patient is demonstrating improved tongue movement and control, food can be pulled to the center of tongue for a cohesive bolus and can be swallowed safely with no signs or symptoms of aspiration.
Assessing Mechanical Soft and Solid Consistencies – “But, they did not penetrate……..”
Assessing mechanical soft on an MBSS is not just to ID penetration and aspiration, but also oral manipulation, control and breakdown. The MBSS is able to show us if breakdown of the bolus really occurs and if not then we are able to see if the whole unmasticated pieces of MS or solid are subject to posterior bolus leakage and/or retention in the pharyngeal space. This can also be a precursor to determining if whole meds may be subject to getting lodged pharyngeally as well. We have observed many instances where whole pieces of fruit are swallowed without incident on the first trial and then asphyxiate the airway on the second trial. Swallowing whole pieces of food when you have premature loss to the pharyngeal space increases risk of airway penetration or obstruction. If a patient does not penetrate on MS or solid but presents increased risk of airway obstruction due to reduced breakdown, the consistency may not be recommended when the patient and the whole medical status and history is taken into consideration.
G- Codes and NOMS With every new year comes new requirements. A claims data collection system is being implemented so that CMS can determine how functional limitations change as a result of therapy services. G codes will need to be reported at evaluation, every 10 treatment days, and at discharge. The score on the 7 point scale of modifiers may be determined by using NOMS. This new Value Based Purchasing strategy requires us to prove the right service to the right patient for the right amount of time AND demonstrate that the patient makes appropriate amount of functional change. The payor sources are wanting know what they are getting for the money. Since an evaluation is considered a treatment day, you will see the G-code and modifiers and the NOMS rating for current status and goal on the DiagnosTEX reports. We will make these ratings based on our MBSS and the physiology/pathology of the swallow.
CH = 0% impaired, limited (NOMS level 7)
CI – AT least 1% but less than 20% impaired, limited, or restricted (NOMS level 6)
CJ = AT least 20%, but less than 40% (NOMS level 5)
CK = AT least 40% but less than 60% (NOMS level 4)
CL = AT least 60 % but less than 80% (NOMS level 3)
CM = At least 80 % but less than 100% (NOMS level 2)
CN = 100% impaired, limited or restricted (NOMS level 1)
Dysphagia Tidbit – Dysphagia and Aspiration Post Stroke www.ebrsr.com
Robert Teasell, MD, Norine Foley MSc, Rosemary Martino PhD, Sanjit Bhogal MSc, Mark Speechley PhD
- There is a high incidence of dysphagia and aspiration following acute CVA
- MBSS are the only sure way to diagnose dysphagia and aspiration
- Enternal tube feeding may be necessary when stroke patients fail to meet nutritional needs orally. There is no difference in the outcomes of death or poor outcome associated with the use of either nasogastric or gastro-enteric feeding tubes.
- The risk of developing pneumonia following CVA is proportional to severity of aspiration.
- Dysphagia diets, consisting of texture modified solid food and thickened liquids may help reduce the incidence of aspiration pneumonia.