Demonstrating the Value of Speech-Language Pathology Services in the Patient Driven Payment Model (PDPM)

Know Your Value!

The Patient Driven Payment Model (PDPM) for Medicare reimbursement was implemented in skilled nursing facilities (SNFs) on October 1, 2019. PDPM pays based on individual clinical characteristics. Here are some ways speech-language pathologists (SLPs) can demonstrate their value in this payment model.

Identify and Provide Comprehensive Coding of Patient Needs

SLPs play a critical role in identifying patients who would benefit from skilled services for speech, language, voice, swallowing, and/or cognitive disorders. Accurate and comprehensive coding that recognizes all relevant diagnoses and comorbidities/complexities is critical to ensure speech-language pathology services are appropriately reimbursed. In addition, improved coding accuracy provides Medicare with more complete data on the conditions for which SLPs are providing services, which could support advocacy efforts to make positive payment policy changes.

Under PDPM, payment for treating patients with speech-language pathology needs are determined by the presence of the following five case-mix factors:

The patient’s primary diagnosis;
The presence of one or more of 12 comorbidities (aphasia; CVA, TIA, or stroke; hemiplegia or hemiparesis; TBI; tracheostomy care while a resident; ventilator or respirator while a resident; laryngeal cancer; apraxia; dysphagia; ALS; oral cancers; speech and language deficits);
A mechanically altered diet;
A swallowing disorder; and/or
A cognitive impairment.

Improve Quality of Care and Compliance

SLPs play an imperative role in ensuring quality improvement and avoiding payment adjustments under the value-based purchasing program (VBP), the quality reporting program (QRP), the annual survey and certification process, and Nursing Home Compare.

For example, SNFs with high readmission rates to hospitals or other negative quality metrics could receive a 2% payment reduction. In addition, SNFs found out of compliance with Medicare survey and certification standards can face civil monetary penalties. Helping your administrator understand the role SLPs can play in compliance and quality improvement reinforces your value beyond the per-diem payment.

In addition to understanding Medicare requirements, SLPs should think about what quality issues might be arising in their SNFs based on their caseload or recent in-service trainings the SNF has provided to its employees. Speaking with your administrator about your role in addressing issues within the individual SNF helps ensure SLPs maintain employment and patients receive safe, high-quality care.

Help Complete the Minimum Data Set (MDS)

Engaging SLPs in the completion of relevant sections of the Minimum Data Set (MDS) ensures accuracy of the data, helps identify patients who need speech-language pathology services, and facilitates interprofessional practice. It can also ensure accurate reimbursement to the SNF when patient needs are identified in a timely fashion. SLPs can contribute to this process either directly or in consultation with the MDS coordinator.

Section K: Swallowing and Nutritional Status
- K0100A Loss of liquids/solids from mouth when eating or drinking
- K0100B Holding food in mouth/cheeks or residual food in mouth after meals
- K0100C Coughing or choking during meals or when swallowing medications
- K0100D Complaints of difficulty or pain with swallowing
- K0100Z None of the above
- K0510C2 Mechanically Altered Diet While a Resident
Sections B & C: Cognition
- BIMS
  - C0200 Repetition of three words
  - C0300 Temporal orientation
  - C0400 Recall
- CFS
  - B0100 Coma and completely dependent or ADL did not occur
  - C1000 Severely impaired cognitive skills (C1000 = 3)
  - B0700, C0700, C1000
    - Two or more of the following:
      - B0700 >0 Problem being understood;
      - C0700 =1 STM problem;
      - C1000>0 Cognitive skills problem; and
    - One or more of the following:
      - B0700 >=2 severe problem being understood;
      - C1000 >=2 severe cognitive skills problem
Sections I & O: Clinical Category
- I4300 Aphasia
- I4500 CVA, TIA, Stroke
- I4900 Hemiplegia or Hemiparesis
- I5500 Traumatic Brain Injury
- I8000 Laryngeal Cancer
- I8000 Apraxia
- I8000 Dysphagia
- I8000 ALS
- I8000 Oral Cancers
- I8000 Speech & Language Deficits
- O0100E2 Tracheostomy Care While a Resident
- O0100F2 Ventilator or Respirator While a Resident

Serve as a Resource to the Interdisciplinary Care Team to Ensure They Identify and Meet All Patient Needs

All disciplines must step outside their silos and collaborate more to ensure that patients receive adequate care. Facilities must remember that SLPs can improve/enhance goal achievement in other disciplines through effective communication when a patient presents with communication and/or cognitive deficits.

Avoid Errors in Documentation and Claims Submission

SLPs play a critical role in ensuring documentation supports the claims submitted by the facility. They can help avoid negative audit findings such as:

Changes in payment that result from changes in the coding or classification of SNF patients versus actual changes in case mix.
Development of patient-centered plans of care, including frequency and duration of treatments, modes of treatment, and maintaining compliance with the group and concurrent therapy limit, if applicable. Individualized, patient-centered plans of care are required by Medicare regulation.
Appropriate identification of swallowing disorders and/or the need for mechanically altered diets.
Identifying and addressing cognitive deficits when indicated.
Discharge planning and recommendations to promote safe transitions and minimize risk of re-hospitalization.