Documentation of Skilled Versus Unskilled Care for Medicare Beneficiaries

Speech-Language Pathology Services

Documentation Examples

Medicare guidelines state that all services must be medically necessary and be provided at a level of complexity and sophistication that requires a speech-language pathologist to perform the tasks. They further stipulate that the interventions provided "require the expertise, knowledge, clinical judgment, decision making and abilities of a therapist that assistants, qualified personnel, caretakers or the patient cannot provide independently" ( Medicare Benefit Policy Manual, Chapter 15, Section 220.3B [PDF]).

What are examples of skilled services?

Speech-language pathologists use their expert knowledge and clinical decision-making to perform the skilled services listed below.

Analyze medical/behavioral data and select appropriate evaluation tools/protocols to determine communication/swallowing diagnosis and prognosis.
Design plan of care (POC) including length of treatment; establishment of long- and short-term measurable, functional goals; and discharge criteria.
Develop and deliver treatment activities that follow a hierarchy of complexity to achieve the target skills for a functional goal.
Based on expert observation, modify activities during treatment sessions to maintain patient motivation and facilitate success.

Increase or decrease complexity of treatment task.
Increase or decrease amount or type of cuing needed.
Increase or decrease criteria for successful performance (accuracy, number of repetitions, response latency, etc.).
Introduce new tasks to evaluate patient’s ability to generalize skill.

Engage patients in practicing behaviors while explaining the rationale and expected results and/or providing reinforcement to help establish a new behavior or strengthen an emerging or inconsistently performed one.
Conduct ongoing assessment of patient response in order to modify intervention based on:

patient performance in treatment activities;

patient report of functional limitations and/or progress.

Ensure patient/caregiver participation and understanding of diagnosis, treatment plan, strategies, precautions, and activities through verbalization and/or return demonstration.
Train and provide feedback to patients/caregivers in use of compensatory skills and strategies (e.g., feeding and swallowing strategies, cognitive strategies for memory and executive function).
Train caregivers to facilitate carry-over and generalization of skills.
Develop, program, and modify augmentative and alternative communication system (low tech or high tech).
Instruct patient and caregiver in use and care of communication system.
Develop maintenance program—to be carried out by patient and caregiver—to ensure optimal performance of trained skills and/or to generalize use of skills.
For patients with chronic or degenerative conditions, evaluate patient’s current functional performance; provide treatment to optimize current functional ability, prevent deterioration, and/or modify maintenance program ( Medicare Benefit Policy Manual, Chapter 15, Section 220.2 C&D [PDF]).

What are examples of unskilled services?

Unskilled services do not require the special knowledge and skills of a speech-language pathologist. Skilled services that are not adequately documented may appear to be unskilled. Unskilled documentation examples are listed below.

Report on performance during activities without describing modification, feedback, or caregiver training that was provided during the session (e.g., patient was 80% accurate on divergent task; patient tolerated diet [or treatment] well).
Repeat the same activities as in previous sessions without noting modifications or observations that would alter future sessions, length of treatment, or POC (e.g., continue per POC, as above).
Report on activity without connecting the task to the long- or short-term functional goals (e.g., patient has treatment plan to address intelligibility related to dysarthria, but the note simply states "patient able to read a sentence and fill in the blank on 90% of trials").
Observe caregivers without providing education or feedback and/or without modifying plan.

The interpretation of Medicare guidelines and examples above are consensus-based and provided as a resource for members of the American Speech- Language-Hearing Association.