On a May 6, 2014, Skilled Nursing Facility (SNF) Open Door Forum,
the Centers for Medicare & Medicaid Services (CMS) clarified existing policy
regarding the coding of evaluations in the Minimum Data Set (MDS).
- The interpretation that any additional evaluation after the
initial evaluation-regardless of the condition-is considered a re-evaluation is
- Coding of re-evaluations in the MDS is only appropriate if
the re-evaluation is of a current condition that is being treated.
CMS MDS is not based on Current Procedural Terminology (CPT) codes; therefore,
evaluations and re-evaluations of the same condition should not be counted in
the MDS, even if the record system used requires speech-language pathologists
(SLPs) and therapists to code their sessions based on CPT codes.
shared an example using cognition and swallowing. If the initial evaluation upon
admission to the SNF was for cognition and a subsequent re-evaluation
for cognition was performed, that re-evaluation is counted in the
minutes for the MDS.
However, if the initial evaluation was for
cognition and later in the course of treatment a
swallowing evaluation is performed, the swallowing evaluation
is not counted in the minutes for MDS, because it is a new condition that was
not in the current treatment plan and is, therefore, a new evaluation rather
than a re-evaluation.
CMS recommended that SNFs ensure that their
processes for coding MDS minutes are consistent with the CMS clarification.
CMS also announced that updates to the Resident Assessment Instrument
(RAI) Manual are expected to be released in September or October of this
Medicare guidance for Part A (inpatient) services
is found in the Resident
Assessment Instrument (RAI) Version 3.0 Manual. The manual provides
specific direction about therapy services in Chapter 3, Section O. The MDS is a
comprehensive summary of the patient's mental and physical issues, completed by
the fifth day after admission to an SNF. Minutes in the MDS are recorded in
1-minute increments for the therapist's time spent in treatment, not initial
evaluations or documentation.
For more information, see ASHA's
Medicare Guidance for SLPs in Skilled Nursing Facilities (SNFs). Questions
may be directed to the health care economics and advocacy team at [email protected].