Medicare Law and Dysphagia Evaluation

BY: Karlene Stefanakos, M.A., CCC-SLP on Thursday, 11 August 2011. Posted in All, Dysphagia, Speech Evaluation, Speech Pathology

It is interesting to note what is expected of the Speech Language Pathologist in Medicare law as regards the appropriate evaluation of the dysphagia patient. To quote the law:  “If you conduct videofluoroscopic assessment (modified barium swallow), document that the exact diagnosis of the swallowing disorder cannot be substantiated through oral exam and there is a question whether aspiration is occurring. The videofluoroscopy assessment should be conducted and interpreted by a radiologist (often with assistance and input from the physician and/or individual disciplines). The assessment and final analysis and interpretation should document a definitive diagnosis, identification of the swallowing phase(s) affected, and recommend the treatment plan. “ (Medicare Intermediary Manual, Part 3 – Claims Process, Transmittal No. 1528, section 450. Subsection D, paragraph 2).

Now what does all this mean for the  SLP at bedside and in the radiology department.  I think the key words in this passage are “definitive diagnosis.” What is a definitive diagnosis? A definitive diagnosis  necessarily is etiologically based, not symptomatically based.  Now what does this mean? Well, f88or example, all SLP symptom verbiage such as  “ valleculae pooling,”” pyriform sinus pooling,”” delayed swallow,” “poor A-P transfer,” “pharyngeal residue,” do not meet the standard of the law regarding diagnosis of etiology of the patient’s dysphagic disorder. An etiology based diagnosis concerns itself with a deeper understanding of the neuroanatomy and physiology of the dysphagic disorder. This is to say that when a dysphagic person exhibits slowed bolus passage into the valleculae with resulting pooling of bolus, the patient is not initiating the cessation of respiration and the activation of the swallow “program” in the brainstem at the primary site of swallow  initiation on the lower lingual base after the apneic reflex is triggered at the anterior fauces. And what is the etiology of this systemic failure?  Is it a sensory deficit on the posterior linguam, is it a motor deficit in the lingual musculature, what motoric innervation neural pathways are affected, are there reflex deficits and which reflexes are diminished, or deficit? What specific muscles are exhibiting diminished range of motion in contractile function. It is the answers to these questions that provides the SLP with a definitive diagnosis of the dysphagia’s components of failure that will generate “an appropriate treatment plan.” Usually receiving SLP’s just receive a list of symptomatic jargon which has been developed by ourselves, which bear no transferable knowledge to the medical professionals we work with. Under the law, we are responsible for the transference of etiological information which can be understood by all members on the patient’s rehab team. For the physician and SLP, this transference of information is best understood in terms of the neuroanatomy and physiological deficits as they are exhibited in the patient’s evaluation. For the nurse, SLP, and CNA this transference of information is best understood in terms of the functions  of the swallow that have been affected.  But, effective transference of accurate etiological information regarding the “true origins of the patient’s dysphagia” is mandated in the law, and is required for a targeted, appropriate treatment plan. Citation of origins of dysfunction is the only manner in which an SLP can address the deficits in treatment and effect a positive outcome for the patient.   Symptomatic listing is what gets the patient to the evaluation, it is not what should come out of an evaluation.

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