August 1, 2013 Departments

On the Pulse: Audit-Proof Your Documentation

Inadequate documentation can make a skilled service appear unskilled. Avoid denials by showing why and how your services are “skilled.”

On the Pulse: Audit-Proof Your Documentation

The words “RAC audit” strike fear in the hearts of clinicians and administrators alike.

Charged by Medicare to reduce improper payments, Medicare’s Recovery Audit Contractors review documentation of services already reimbursed by the Centers for Medicare and Medicaid Services. But if the RAC later deems the services inappropriate, the provider must repay the funds. And, according to CMS, one of the primary reasons RACs deny speech-language pathology services is lack of documentation that the services are “skilled.”

Skilled services are one aspect of meeting the “reasonable and necessary” requirement for a covered service by Medicare. The Medicare Benefit Policy Manual [PDF] states that that these services “require ... the expertise, knowledge, clinical judgment, decision making and abilities of a therapist that assistants, qualified personnel, caretakers or the patient cannot provide independently.”

For clinicians, Medicare mandates a twofold obligation: You need to deliver services that require your skilled decision-making ability as a qualified provider, and document what you did in a way that conveys why it was skilled.

Skilled activities involve:

  • Continuous assessment and interpretation of patient performance.
  • Adjustments that must be made to help the patient achieve appropriate functional goals.

Unskilled services are:

  • Repetitive tasks or exercises that don’t involve any variation in complexity, level of cueing or progressive independence.
  • Performed by observing the patient’s or caregivers’ performance of learned activity with no feedback.

Routinely observing a patient eating and reminding the patient to use compensatory techniques is not skilled service. What is skilled is analyzing the patient’s response to skilled techniques; implementing a cueing hierarchy to increase safe per os (by mouth) tolerance of recommended diet; and promoting the patient’s progressively independent use of strategies to maximize swallow safety.

Some electronic documentation systems help you by including categories that cue you to report skilled activities, but you need to provide details about the services you provided and the observed and anticipated benefit. For example, “Caregiver education was completed” is not sufficient. Specify who and what was trained, how you established the caregiver’s success in implementating strategies, and the patient’s response to the caregiver’s strategies.

Skilled documentation includes information such as:

  • Rationale for how the activity relates to the functional goal.
  • Objective data showing progress toward goal such as accuracy, speed, frequency, independence and physiologic variations.
  • Education or feedback provided to patient and caregiver.
  • Modification of activities, goals or the plan of care based on the patient’s performance.

If you report the same activity over successive sessions without describing any modifications or feedback you provide, your sessions could be denied. But when you document the feedback and reinforcement provided during the activity to help establish this newly emerging skill, it becomes skilled.

For more help with service documentation, see our website.

Monica Sampson, MA, CCC-SLP, is a member of ASHA’s Health Care Services in Speech-Language Pathology team.

Gennith Johnson, MA, CCC-SLP, is a member of ASHA’s Health Care Services in Speech-Language Pathology team.

Janet Brown, MA, CCC-SLP, is a member of ASHA’s Health Care Services in Speech-Language Pathology team.

cite as: Sampson, M. , Johnson, G.  & Brown, J. (2013, August 01). On the Pulse: Audit-Proof Your Documentation. The ASHA Leader.


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