MCI/Dementia: Writing Caregiver Education into Clients' Plans of Care

Editor's Note: This text is an edited transcript of the course MCI/Dementia: Writing Caregiver Education into Clients' Plans of Care presented by Allison Gallaher, MS, CCC-SLP.

Learning Outcomes

After this course, participants will be able to:

• Define “family-centered care.”
• List at least one way in which inclusion of caregivers in intervention improves outcomes.
• Describe how to write a caregiver education goal.

Introduction

It's such a pleasure to be here again and spend this hour with you all. Let's get right into it. First, I'll discuss our current plans of care, which often follow a typical formula. I'll address part of that and then look at evidence suggesting we need to shift away from it, particularly by including caregiver education in our plans. We'll explore why we might not already be doing this and identify barriers to including caregiver education. Hopefully, we'll have time to collaborate, develop some goals, and review a couple of cases from my practice.

As a medical provider, our work with mild cognitive impairment and dementia often involves dysphagia or swallowing therapy. While today's discussion is relevant to these patient populations, I recommend Dr. Debra Suiter's excellent 90-minute course (Course 9708) for detailed information on incorporating caregivers and addressing caregiver burden for dysphagia. My clinical practice focuses on cognitive-communication, which will be the focus of our goals and cases today.

Do Your Written Goals Include Caregivers?

First, before we begin, I want to reflect on the most recent plan of care you wrote. Maybe it was yesterday or this morning. Think about it and the goals you wrote down. Was anything related to caregivers specifically in your written goals?

Maybe the answer is yes, or maybe it's no. Take a moment to reflect on that. Often, our documentation focuses heavily on the individual we're helping—our client or patient—and on us as therapists. Our goals frequently create a false dyad between therapists and clients. The goals might say, "I, as a therapist, will give a visual cue or a model, and that will induce a target behavior in the client or patient." For instance, the client might recall something. This sets up the false dyad I mentioned between our clients and ourselves.

If you are a brand-new SLP or haven't seen someone with dementia or mild cognitive impairment in a while, you might not know how to write a cognitive rehabilitation goal for that person. You might pull up a web browser, search online, and come across some great goals. That's what happened when I looked up goals for mild cognitive impairment. You might find a goal like this: "A client will use internal memory aids to recall the steps of a simple recipe in a natural setting with 75% accuracy."

On paper, this is a great goal. It's measurable, achievable, and has a specific target behavior. But again, this goal reflects the false dyad approach. Who is training the internal memory aid? It's me, the clinician, doing something that creates a target behavior in the client. The client is recalling the steps of a simple recipe. This cyclical relationship focuses solely on the patient and ourselves.

Similarly, consider another goal: "The patient will answer personal information using a memory book given intermittent moderate verbal cues." Here, you can see the components of what the client is doing and what we are doing to induce that behavior. Our cueing, with intermittent moderate verbal cues, is our action, and the patient's behavior is answering personal information. This is a typical formula for goals in your plan of care.

This setup raises the question: what happens after discharge? As therapists, our ultimate goal is generalization to functional contexts. But if our goals focus solely on the interaction between us and the patient, our cueing, and the patient's behavior, what happens when we are no longer there to provide cues? Are we truly setting our clients and patients up for success, especially knowing that this patient population often has a progressive condition? The progression of the disease means these patients tend to deteriorate over time. So, is this a good way to write a goal for this patient population?

So we might ask ourselves, "Can we do better? Can we rise above the typical formula for writing a goal and look to leveraging those lovely existing supports in that patient or client's life?"

Family-Centered Care

This leads us to family-centered care, part of a larger movement in healthcare. Historically, we've followed a patriarchal model, where the provider prescribes something, and the patient follows it. The family-centered model expands beyond the therapist-patient dyad to include the patient's chosen family. Note that this chosen family isn't necessarily biologically related. In my practice, I've seen nephews' girlfriends, close neighbors, coworkers, or ex-spouses involved in care. This is directed by the patient or client, who chooses their family, emphasizing collaboration with these people.

The goal of family-centered care is to collaborate with the patient's chosen family to promote their health and well-being, allowing the patient and their family to maintain control. This shift away from the therapist-patient dyad to include the family and caregivers is crucial.

It's important to note that this approach aligns not only with the family-centered care model but also with the World Health Organization's International Classification of Functioning. The WHO asks us to "modify contextual factors that might serve as barriers or facilitators of successful communication and participation."

This is important for us as providers because modifying contextual factors means interacting with and changing the views and behaviors of the people around our patients and clients. It asks us to include ancillary supports in our efforts to support the patient. We're aligning with a larger paradigm shift in healthcare, but shifting paradigms can be challenging. It's important to recognize why this shift might be worthwhile.

As we consider whether our current goals include caregivers, let's reflect on this quote from Alyssa Lanzi from the University of Delaware, who has done great work on counseling roles for mild cognitive impairment:

"A family-centered approach might be worthwhile with any etiology in healthcare as a speech therapist, but it's all the more important here with this patient population for a number of reasons."

This highlights the significance of a family-centered approach, especially for our patients with mild cognitive impairment.

Including Caregivers Improves Outcomes

Those with dementia and mild cognitive impairment are major consumers of our services. The odds of encountering someone with mild cognitive impairment or dementia are high. These patients are significant consumers of our services. Alyssa Lanzi further states that services for this population are not limited to direct assessment and treatment but also include counseling, collaboration, prevention, and wellness. If we haven't already shifted from a dyad approach to family-centered care for other etiologies, this shift becomes critical when working with patients with dementia or mild cognitive impairment.

If that's not reason enough, let's consider what we want as SLPs. We enter this field to improve outcomes for our patients. I'll go through a few studies that provide compelling data supporting the idea that involving caregivers in plans of care improves outcomes. 

Bourgeois 2019 Study

Let's take a look at research from Michelle Bourgeois out of Florida. She conducted extensive studies over decades on dementia populations, summarized in a 2019 article. Her findings show that involving both paid and unpaid caregivers—whether staff in residential facilities or family members—promotes the generalization of trained behaviors.

For example, in a residential facility with five hallways, two hallways were randomly selected for a study. Residents in these two hallways were trained to use a memory book, and both the SLP and nursing assistants were trained to prompt the residents to use the book. In the other three hallways, only the speech therapist provided the training.

As expected, training caregivers multiplied the effect and dosage of the intervention. Instead of a single 30-minute session each week, the impact was multiplied by having caregivers prompt the use of the memory book regularly. This approach significantly increases the frequency and reinforcement of the desired behavior.

When we, as SLPs, train not only the patient but also caregivers—such as spouses—to prompt the use of memory aids at home, we multiply our impact. This method of "multiplying" ourselves through caregiver training enhances the overall effectiveness of our interventions.

Trouche 2019 Study

Another important study suggests that direct training or involvement improves communication in individuals with memory impairment. This study, conducted by the University of Central Florida, adapted a treatment originally designed for individuals with aphasia, known as Supported Conversation for Adults with Aphasia, for people with dementia.

The Supported Conversation for Adults with Aphasia focuses on training the conversation partner—whether a spouse, loved one, or caregiver—on how to modify their interactions with individuals with dementia or memory impairment. The goal is to affirm the competence of individuals with memory impairment and reduce unproductive coping behaviors.

In this study, unproductive coping behaviors were identified, such as increasing volume in response to a memory lapse, joking about a memory lapse, or quizzing. A common scenario involves well-meaning caregivers quizzing their loved ones with memory impairment, asking questions like, "Where did we go to dinner last night?" instead of providing cues.

The study, which included four dyads (four spouses and four individuals with memory impairment), observed these pairs over four weeks. The results showed not only a reduction in unproductive coping behaviors from the spouse caregivers but also greater participation from the individuals with memory impairment. When not subjected to quizzing, individuals with memory impairment were more incentivized to engage in conversation.

This is important for us because it highlights that effective communication with individuals with memory impairment requires skill acquisition from both the caregivers and the patients. If we focus only on the patient, we miss half of the picture. Training caregivers to provide supportive cues instead of quizzing can lead to significant improvements in communication and participation.

For example, if we notice a caregiver quizzing their loved one, we can suggest, "Instead of asking him where we went to dinner last night, try saying, 'We went to an Italian restaurant last night.' This cue can support his recall and encourage his participation in the conversation." This approach fosters a more supportive and effective communication environment for individuals with memory impairment.

Hoben 2023 Study

Another study suggesting that involving caregivers improves outcomes comes from a survey conducted in Western Canada during COVID-19. Over 300 caregivers of loved ones in care facilities were asked about their perceptions of the care given to their loved ones and how often they were able to visit and be involved. During COVID-19, opportunities for caregivers to visit and be involved were significantly reduced. The results showed that when caregivers are less involved, they perceive the quality of care and outcomes for their loved ones as poorer.

This suggests that even if the actual outcomes do not change, involving caregivers can improve their perception of the effectiveness of our therapy and interventions. It's like the visual of a dog happy to be along for the ride—caregivers feel better and more engaged when they can participate in the care process.

I've seen caregivers who look burnt out, thinking I was helping by suggesting they take a break. However, these survey data support the opposite: involving caregivers gives them a sense of agency, aligns with family-centered care, and may lead them to believe our care is more effective. This is compelling evidence that involving caregivers can enhance their perception of care quality and effectiveness.

Badesha 2023 Study

Another compelling study suggests that caregiver burden or quality of life measures and care recipient outcomes are linked. Badesha's work indicates that if SLPs reach out to caregivers, support them, and address their needs, it leads to better patient outcomes.

For example, we might say to caregivers, "Hey, how's it going for you? What do you need? What are the pain points at home? Is it repetitive questioning that's difficult for you? Is it misplacing items? How can I help you?" By coming alongside and supporting caregivers, we can significantly improve the patient's outcomes. This approach shows that direct intervention with caregivers has a positive impact on the patient.

This meta-analysis in speech therapy reviewed over 1,800 studies and examined how speech therapists' interventions specifically addressing caregiver burden can influence patient outcomes.

Of the small number of studies where SLPs directly interfaced with caregivers, all showed improvements not only in the caregiver's quality of life but also in the participation of the care recipient, our patient. These interventions often involved an SLP working with a caregiver for an hour a week over four weeks, discussing tips and strategies to improve the caregiver's quality of life. Sometimes, this was done in tandem with another healthcare professional, like a social worker, and the patient was not present during these sessions. This demonstrates that direct interaction with caregivers can have positive effects on our patients.

What this means for us is clear. When we reach out to caregivers and ask, "What's going on? How can I support you?" addressing their pain points makes them better caregivers. In turn, they feel more fulfilled and capable of providing good care to the patient. By supporting the caregivers, we indirectly support the patients.

Involving Caregivers - Trending Toward Law!

Another reason to consider shifting to family-centered care and including caregivers in our documentation is that this trend is becoming law. If you work in an acute care setting, you may have heard of the Caregiver Advise, Record, and Enable (CARE) Act, which stems from work by the AARP. This Act has been adopted by over 44 states and territories. It mandates that hospitals record a family caregiver, document their name, inform them of the patient's discharge, and educate and instruct them on the medical tasks they will perform at home.

This is important for us to know and recognize because it indicates a significant trend toward formalizing the inclusion of caregivers in patient care plans. If this is not something we are already doing, it's important to note the increasing legal requirements and the supporting evidence that including caregivers in our plans of care benefits the patient and improves outcomes.

Let's take a moment to reflect on whether we are currently incorporating caregivers into our care plans. Considering the data that show the positive impact of involving caregivers, it's worth examining our practices and making adjustments to align with this evolving standard of care.

Potential Barriers

Insurance Providers

One potential barrier is insurance. You might be thinking, "Allie, I hear that you want me to write a caregiver goal, but that's not what insurance wants to see. Insurance wants to see that we're doing something skilled and causing a change in the patient's functioning." Insurance often emphasizes the therapist-patient dyad, where the therapist performs a skilled intervention, resulting in a change in the patient's functioning. However, when we talk about "skilled" services, it's essential to consider that, according to the ASHA Practice Portal, skilled services include not only materials and strategies but also patient and family education. ASHA directs us to document skilled interventions that encompass education, suggesting that including caregiver goals in our plans of care is valid.

Regarding insurance, there's significant news as of 2024. You may know that Medicare often sets the precedent for other insurance providers. As of 2024, Medicare B, which oversees outpatient services, has introduced new CPT codes. These codes now consider patient caregiver education as a billable and recoverable service, even without the patient present. This means we can interact with the caregiver for up to 30 minutes, providing them with strategies to support the patient's cognitive-communication functioning, and this interaction is now a billable service.

If you work in an outpatient setting, I encourage you to discuss these new codes with your directors of rehab and include them in your superbills. Additionally, you can add 15-minute intervals after the initial 30 minutes, and there's a new CPT code for group sessions. It's important to note that these codes apply to current patients with a developed plan of care. You are not just always seeing the caregiver; the patient must be on your caseload and actively receiving skilled services

This development is exciting because it signifies federal recognition of the benefits of educating caregivers. Medicare acknowledges that this is worthwhile, and other commercial insurance will likely follow suit. Therefore, including caregiver goals in your plans of care is not only beneficial for the patient's outcomes but is also supported and billable under current insurance guidelines.

Availability of Caregiver

Maybe insurance isn't your barrier, but instead, you're thinking, "It's difficult to pin down this caregiver." Perhaps it's a different person each time, or you only have a few minutes with the caregiver, leading you to avoid writing goals specific to caregiver education for your patients with memory impairment because the caregiver isn't consistently present.

Here are some suggestions to address this barrier using technology. In the digital age, we can leverage available technology to interface with caregivers more effectively. Consider scheduling a five-minute Zoom call with a caregiver who might be in a different state or at work while you're seeing their loved one. This allows them to see, experience, and be part of your plan of care, not only for training purposes but also for collaboration. You can ask, "What's going on at home? How can I support you? What are your pain points, and how can we address them?"

Another approach is to make the most of the limited time you have with caregivers. If you only have a few minutes at the beginning or end of a session, or if their availability is intermittent, use those moments effectively. I've definitely been guilty in my practice of using those couple of minutes to preach to someone. "I know what I need to do as the expert, and I'm going to say all of these things, give good education, and feel really good about myself. I just said all of these things; the caregiver's going to take that and run, right?" Maybe.

Adult learning theory supports that we learn by doing things. So, can we use those few precious moments at the beginning and end for practice? Instead of just saying, "Hey, I would like you to cue your loved one instead of quizzing them," can we have an interaction and provide hands-on practice?

That might be a great way to involve your caregiver in your plan of care. If that's still not possible, and you never see the caregiver in person or they're not available, at the very least, we can send a survey home with the patient. These can include the Caregiver Burden Inventory or the Caregiver Self-Assessment Questionnaire. These are free, readily available, 30-point questionnaires online. You can print them out and provide them to the caregiver to solicit input on what's going on at home and how you can support them, which might change your interactions with the patient.

As an aside, the Caregiver Self-Assessment Questionnaire is translated into several languages, including Spanish and Russian, which can be helpful if there is also a language barrier for the caregiver.

Training

Another potential barrier to including caregiver training and education in our plans of care is the lack of training on how to do that. We might have been trained in a very dyad, patriarchal model and may not have been shown how to make this shift.

A recent study by Chen in 2021 surveyed speech therapists about their views on caregiver burden. The study found that 92% of respondents acknowledged caregiver burden as a significant issue that can impact our work with patients, but fewer than 45% felt well-prepared or well-trained to address it head-on.

It's possible that you haven't received this type of training before. So, here are a few resources that might be helpful:

1. Psychosocial Support: Are you aware that every town has an assigned social worker you can reach by phone at 211 or through 211.org? They can provide information on local practical supports that might relieve some of the caregiver's pressure.

2. Local Mental Health Providers: Recommending a local mental health provider to the caregiver can also be beneficial.

Another option is an evidence-based program called Powerful Tools for Caregivers, which I am trained in. This free and readily available program is often offered by your Centers for Healthy Aging and is also available online at various times. It's a 90-minute course held over six weeks that addresses how caregivers can change their mindset and provides tools to make the often difficult and unpaid task of caregiving feel less burdensome. I highly recommend this course.

Additionally, the Family Caregiver Alliance offers support for those who might be stretched thin and unable to commit to a 90-minute weekly course. They provide a free 24/7 national hotline staffed by social workers. This hotline offers trained professionals who can listen to and address the difficulties caregivers face. There is also a chat function available for convenience.

If the issue is that you've never been trained to write caregiver goals, let's work on that together. We'll look at how we can rework some of the goals from lightly fictionalized cases from my own practice. Instead of stating, "The patient will do this because I, as a speech therapist, did this," we can explore how to frame goals that incorporate caregiver education and involvement.

Case 1. This might be a very typical cognitive rehabilitation client you would have. You are working with a 78-year-old man named Keith. He's a retired plumber living with his longtime partner, Susanna. Keith is in the early stages of Alzheimer's disease.

Keith and Susanna are both aware of his diagnosis, and they share a common frustration: Keith cannot retain daily information. It's like trying to hold onto sand. For example, Susanna tells him, "Today, we are going to Tai Chi at 10." Keith responds enthusiastically, "All right, awesome. I'm pumped, can't wait to go to Tai Chi." But 15 minutes later, Keith asks, "Susanna, what are we doing today?" Susanna sighs and repeats the information. This constant repetition is leading to frustration for both of them. You might readily know how to intervene to support Keith and help him retain information.

How would we write a goal specific to training Susanna? What behaviors and target actions can we support Susanna in doing? One way is to say that following a model provided by the therapist, Susanna will demonstrate reference to the FAQ log using the consistent phrase, "Oh, that sounds important. We write important things here," to support Keith's access to personally relevant information.

As the therapist, you model this behavior by saying, "Oh, that sounds important. We write important things here," every time Keith asks a question. This leverages prospective memory by teaching Keith that important information is consistently written in one place rather than trying to teach him something new every day. Susanna is then trained to use the same phrase to reinforce this habit.

Another way is to set a goal where Susanna will demonstrate cueing rather than testing Keith's recall during structured practice when provided with written and verbal education by the therapist. You provide Susanna with written and verbal instructions to use the FAQ log for information instead of testing or quizzing Keith. This involves direct education on why quizzing is maladaptive and how cueing can be more supportive. For instance, you train Susanna to say, "Let's take a look at our FAQ log together," instead of testing Keith's memory. This approach is based on evidence that quizzing is a nonproductive coping mechanism and that consistent cueing can help reduce frustration and improve interactions.

Case 2. Let's take a look at another case. This case is slightly adapted from my own practice. Your patient is a 64-year-old middle school math teacher named Charice. Her caregiver is her adult son, Matt, who lives about six miles away. Charice has a diagnosis of mild cognitive impairment, and her main issue is frequently losing important items like her phone, work badge, and purse. This leads to her calling Matt in distress, crying, and being unable to breathe because she’s so frustrated with herself for forgetting these important things.

We, as therapists, might instantly think about how to support Charice, what behaviors we want to see her do, and how we can cue her. However, let's think about how we might empower and educate Matt to help his mother. For instance, we might consider how to involve Matt in setting up a system to help Charice keep track of her items.

So, how can we write a goal that's helping Matt? What can we do to help Matt do that? Charice has been experiencing intense frustration when she forgets something, which impacts her quality of life and participation. We might support Matt by saying, "Hey, Matt, can we show your mom how to go onto the "breathe mode" on her watch so that she can relax for a second after she's noticed that something's missing?" We can ask Matt to be the one doing the cueing.

There's choral production where I demonstrate to Matt how to access the breathing mode, and then Matt and I both show Charice together. This way, she can become more regulated and better able to find the item.

We know Charice will be in a better spot if she places things in the same place every time. We want to help Matt facilitate this change. We could set a goal where Matt uses a visual model, like colored signage, to indicate the designated spot for her work badge. The goal could be: "Matt will place a sign that says 'work badge' in the agreed-upon location and cue Charice twice daily to use this spot."

Case 3. In this case, your patient is an 80-year-old man named Sanjay, and his neighbor Carl is his chosen family. Carl checks in on Sanjay every single day. Sanjay, who was previously diagnosed with mild cognitive impairment, is now experiencing dementia. He is forgetting important dates like the birthdays of his beloved nieces and nephews, forgetting recipes he loves to cook, and sometimes he believes it is 2024, while other times he thinks it’s 1994. These are some of the pain points Carl is experiencing, and both of them are looking to you for cueing that can support their functioning.

As speech therapists, we might immediately think of several interventions for Sanjay, but let's consider the whole family-centered care approach. What is something we could do to involve Carl and support both of them? What target behavior would we like Carl to adopt? One option could be providing a wall calendar with relevant birthdays written in and asking Carl to cross off the previous day each morning for two weeks to support Sanjay's awareness of these birthdays. Notice that we are not directly asking Sanjay to perform the behavior. Instead, we are modifying the context, as the World Health Organization suggests, to support participation and communication. We are changing how Carl interacts with the world to create a supportive environment for Sanjay.

Another option here is addressing the challenging situation Carl faces as Sanjay's dementia progresses. Carl often has to decide when to correct Sanjay's confusion about the year and when to let him believe it’s 1994. This is a difficult and delicate decision. As therapists, we can educate Carl about how and when to reorient Sanjay, and we want to see Carl demonstrate this reorientation and also demonstrate stepping into Sanjay’s reality in two sessions to support Sanjay’s participation. We know that sometimes, especially when it's late at night or when it’s benign, it might not be worthwhile to insist on the current year. Supporting Carl in making these decisions is important.

In these case examples, the goal is to show how natural it is for us as SLPs to identify the functional challenge and think of ways to get our patients to do something. However, in these examples, we focus on supporting the functioning of the loved one. We aim to train Susanna, Matt, and Carl, and the patient’s chosen family to modify the context and enhance the patient’s functioning. By empowering and educating the caregivers, we can create a supportive environment that benefits both the patient and their loved ones.

For Any Case of MCI

If you're unsure where to start with caregiver education, it's important for almost any case of MCI to provide education on what MCI is and isn't, as well as the modifiable risk factors for MCI converting to dementia. For nearly every patient with MCI, I've written a goal like, "Following education, the caregiver will be able to identify three lifestyle changes that could support the patient's functioning."

If you don't know the modifiable risk factors off the top of your head, I recommend referring to a report from the Lancet Commission, which details 12 modifiable risk factors. These include things like oxygen use if needed, stress management, diet (such as the MIND diet, which Harvard has researched extensively), sleep hygiene, and social engagement. These lifestyle changes are vital for people with MCI because many families mistakenly believe that MCI is just a form of typical aging.

It is not. MCI is an atypical form of aging. Many families come to us with the preconceived notion that nothing can be done and that MCI inevitably progresses to dementia. However, we know that about a third of MCI cases remain stable throughout the patient's life, another third progress to dementia, and the remaining third can see improvements through lifestyle changes addressing modifiable risk factors, allowing the patient to function comparably to their typically aging peers.

Equipping families with this knowledge is important because it can lead to lifestyle changes that have lasting impacts on the patient's memory and overall cognitive health. By educating caregivers on these factors, we can empower them to make informed decisions that support the patient's well-being and potentially slow the progression of cognitive decline.

Another goal I write for caregivers in almost every case is that after providing verbal or written education, the caregiver will change their definition of memory. Many patients with MCI and dementia present with the complaint, "I can't remember." Our immediate response might be to suggest using a sign or an FAQ log, thinking that will solve the issue.

However, it's important to redefine memory at the outset of therapy as, "Can you access that information on command?" Many families come into sessions believing it doesn't count as remembering if the patient can't recall the information off the top of their head. But remember, memory is about accessing information when needed, whether that means recalling it from their head or using written support.

By shifting the caregiver's understanding of memory, we help them see that using tools and strategies to access information is a valid and effective way for their loved one to manage memory challenges. This new perspective can reduce frustration and improve the effectiveness of the memory aids we implement.

Questions and Answers

When you're using Zoom with patients' caregivers, and those caregivers are in a different state than where you are, sitting with the patient, do you have to be licensed in that state where the caregiver is?

Yes, you do. From my understanding, we, as the provider, need to be licensed in the same state as the end user. In this case, the end user is the caregiver, so we would need to be licensed in that state.

Is the caregiver CPT code billable via Zoom or phone, or does it have to be in person?

For now, it has to be in person. We know that there are separate prefixes for telehealth, so to my knowledge, there is not yet a CPT code for telehealth generated. If you have been billing telehealth, you know that it's a different number with a different prefix. These were the only three CPT codes that Med B has presented for this year, but things might change.

Can we use FaceTime for a caregiver out of state?

The answer is similar to using Zoom with patients with the caveat that if I don't bill 97550, if I'm billing my typical code for the patient, and I'm with the patient there, then I can bill that patient for direct care of that patient, and certainly, regardless of the location of the caregiver, I can bring them into that session. That's totally fine. But I can't bill, unless I am licensed in that state. you could bring them in via phone, or whatever, but you can't bill for this, for these codes that I gave you. But, double check everything, because this is very new in usage.

Can we bill the new CPT code and another COG code on the same day?

Yes. Just in the same way that you can bill separate codes, separate speech therapy codes on the same day, you can bill separate, for Med B. That's all for Medicare Part B right now, so that might be different depending on different providers.