SpeechPathology.com Phone: 800-242-5183


EDU Healthcare Opportunities

Documenting in Skilled Nursing Facilities - Part 2

Documenting in Skilled Nursing Facilities - Part 2
Renee Kinder, MS, CCC-SLP, RAC-CT
February 24, 2017
Share:

After this course, readers will be able to:

  1. Identify methods for writing functional, measurable and realistic short-term objectives and long-term goals for restorative and maintenance-based levels of care
  2. Describe how to document levels of care within daily notes
  3. Describe best practices for documenting functional gains made during SLP services in progress reports

Introduction and Overview

This is Part Two of a two-part series on documentation in skilled nursing facilities.  For everyone that was able to participate in Part 1, welcome back. To anyone that is new on today's call, we will be talking about some of the areas from Part 1 to give you a foundation.  We talked about evaluation of plan of care requirements in Part 1; however, Part 2 will focus more on progress reports, goal writing, and discharge summaries. 

This course will describe best practices for documenting skilled levels of care provided by an SLP, including an in-depth review of goal creation, daily note documentation, and progress report writing. In addition, case studies will be used in order to support documentation in your real world settings, to bring everything back to the real world.

We would like for participants to be able to identify methods for writing functional, measurable, and realistic short-term objectives and long-term goals for restorative (meaning rehab) and maintenance-based levels of care. Participants should be able to describe how to document skilled levels of care within daily note documentation. Participants will be able to describe best practices for documenting functional gains made during SLP services within progress reports.

There are two supplemental handouts that were included with the course materials. We will go through the dysphagia goals during this course, but the other handouts are a supplement for your toolkit.

Know Your Regulations

We will start with a general overview of some of the areas discussed in Part 1. The purpose of this course is to provide some guidance on documenting skilled level of care within skilled nursing facilities (SNFs), and it is likely you are treating Medicare patients. There are some key foundational regulations that you need to be in tune with. These include the Medicare Benefit Policy Manual Chapter 15, Sections 220 and 230; the National Coverage Determinations, which are regulations at the national level; and then the Local Coverage Determinations. Local Coverage Determinations are regionally specific regulations, so these will differ depending on your geographic location. They have guidance for CPT coding, ICD coding, as well as the essential areas for documentation.  It is very important to know about these, if you are treating in a skilled nursing facility and you do not know who your Medicare Administrative Contractor (MAC) is, and what the Local Coverage Determinations are for your site. We will go over the four general criteria for reasonable and necessary skilled care that can be found in the Medicare Benefit Policy Manual.


renee kinder

Renee Kinder, MS, CCC-SLP, RAC-CT

Renee currently serves as Clinical Specialist for Evergreen Rehabilitation where she provides education and training programs for interdisciplinary team members related to Medicare regulations, documentation requirements, and evidenced based practice patterns. She is currently Vice President of Healthcare for the Kentucky Speech Language Hearing Association, acts as an Ambassador for the Alzheimer’s Association, has provided caregiver trainings for the Alzheimer’s Foundation of America, and is a member of community faculty for the University of Kentucky College of Medicine. She is a member of ASHA’s Healthcare and Economics Committee and maintains active membership in ASHA Special Interest Groups for Swallowing, Neurology and Gerontology where she is currently Editor of Perspectives on Gerontology.



Related Courses

Treating in the Gray Zone: Post-Acute Care Considerations
Presented by Melissa Collier, MS, CCC-SLP, CHC, CDP
Video
Course: #10066Level: Intermediate1 Hour
This course helps post-acute care clinicians better understand how to approach treatment when things aren’t black and white. It addresses scenarios such as geriatric frailty/weight loss and diet modification, the paradigm shift to a patient-choice model, legal considerations regarding diet waivers, and the care plan process. The SLP's role on the post-acute interdisciplinary team is also discussed.

Building Your Case for Medical Necessity: The Nuts and Bolts of Skilled Therapy Documentation
Presented by Melissa Collier, MS, CCC-SLP, CHC, CDP
Video
Course: #9839Level: Introductory1.5 Hours
This course provides participants with an understanding of documentation requirements in a post-acute setting, including Medicare regulations and guidelines. It identifies why speech therapy services are denied and ways to mitigate the denial of skilled services, and describes how to document medical necessity.

Gold-Standard Documentation Strategies: Medicare and PDPM SNF Documentation
Presented by Lorelei O'Hara, M.A., CCC-SLP
Video
Course: #9673Level: Intermediate1.5 Hours
Scrutiny is the name of the game in skilled nursing facility (SNF) clinical service delivery. This course discusses how to create bullet-proof documentation using appropriate language and coding for Medicare Part A and B claims, and how to support the interdisciplinary team with iron-clad support for patient-driven payment model (PDPM) payment components, including cognitive and mood assessment tools.

Behavioral Frameworks for Dementia Management
Presented by Mary Beth Mason, PhD, CCC-SLP, Robert W. Serianni, MS, CCC-SLP, FNAP
Video
Course: #9473Level: Intermediate1 Hour
This course will focus on cognitive-communication intervention strategies for various dementia presentations and will provide a review of evidence-based treatment. Behavioral frameworks along with their rationales will be introduced and applied across several dementia types and mild, moderate and severe levels of impairment.

Dysphagia in Neurodegenerative Disease
Presented by Debra M. Suiter, PhD, CCC-SLP, BCS-S
Video
Course: #9732Level: Intermediate1 Hour
Dysphagia is common in individuals with amyotrophic lateral sclerosis (ALS) and Parkinson’s disease. This course discusses the underlying pathophysiology and appropriate treatment programs for each disease, as well as use of alternate methods of nutrition/hydration.

Our site uses cookies to improve your experience. By using our site, you agree to our Privacy Policy.