Widespread Targeted Review Results for Iowa Skilled Nursing Facility (SNF) Providers for Speech-Language Pathology Services and Primary Diagnosis Code 787.2
Part A Medical Review has recently completed the 4th quarter widespread
targeted prepay review of SNF non-Prospective Payment System (PPS) claims
with bill type 22X and 23X with a primary diagnosis of 787.2 (dysphagia)
and Current Procedural Terminology (CPT) code 92526 processed between
October 1, 2007, and December 31, 2007. An educational article
providing the results of a previous review was posted on the “What’s
New from Cahaba” Web page on May 2, 2007, and November 26, 2007. The
results of the current widespread review are summarized below:
Claims Reviewed: 54
Claims Denied/Partially Denied: 42
Charges Reviewed: $66,781
Charges Denied: $42,944
Error Rate: 64%
*error rate is based on the charges denied divided by the charges reviewed.
The majority of the services were denied because the medical necessity of the service(s) was not supported in the medical record documentation received in response to the Additional Development Request (ADR).
Dysphagia is a swallowing disorder that may be due to various neurological, structural, and cognitive deficits. Dysphagia may be the result of head trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, and encephalopathies. While dysphagia can afflict any age group, it most often appears among the elderly. Dysphagia services are covered under Medicare by therapists, regardless of the presence of a communication disability.
Dysphagia services are covered provided such services are of a level of complexity and sophistication, or the patient’s condition is such that the services can be safely and effectively performed only by a licensed qualified therapist. Services normally considered to be a routine part of nursing care are not covered. In order for the Plan of Care (POC) to be covered, it must address a condition for which dysphagia services are an accepted method of treatment, as defined by standards of medical practice. There must be an expectation that the condition will improve significantly in a reasonable and generally predictable period of time based on the assessment of the patient’s rehabilitation potential, after any needed consultation with the qualified therapist.
Insufficient documentation for the services provided also accounted for denials. The POC should delineate goals and type of care planned which specifically addresses each problem identified in the assessment, such as compensatory swallowing techniques, proper head and body positioning, amount of intake per swallow, and other needs of the patient. The daily treatment encounter notes must have the skilled interventions documented in order for the dysphagia service to be covered. Merely giving a status report of the kind or amount of food consumed does not support the need for skilled intervention. As noted in the local coverage determination (LCD) (L923), “Dysphagia services are not covered to treat Skilled Nursing Facility (SNF) patients whose care can safely and effectively be rendered by the SNF’s trained professional staff.”
As a result of this review, Part A Medical Review will continue a targeted prepay review of all SNF facilities billing this CPT code and diagnosis code. Also, providers identified through data analysis as driving this aberrancy may warrant provider-specific medical review.
Page last updated: Feb. 28, 2008
