Encore Keynote - July 2021

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- Encore Rehabilitation’s monthly publication, designed to give you updates on trends we are seeing in the SNF/LTC industry. -   


Hydration:  Free Water Protocol

One of the biggest risks of the use of thickened liquids is dehydration. Couple that with the summer heat, and this risk is increased.  The Frazier Free Water Protocol is a program that allows patients with dysphagia to drink water, un-thickened, between meals.

Here are a few highlights of the Free Water Protocol:

  • Water has a neutral pH, and therefore, does not cause chemical damage to the lungs if aspirated, if all outlined precautions are followed.
  • Patients/residents perceptions of swallow-related quality of life appears to improve.
  • Good oral hygiene is a key ingredient of the free water protocol and offers other benefits with regards to swallowing.
  • Water intake is unrestricted prior to a meal, and allowed 30 minutes after a meal.
  • The free water protocol is not indicated for patients/residents who are unable to follow directions or are unable to be compliant with the program's rules.
Please consult with your Speech-Language Pathologist and Medical Director for additional information.

What We can do to Ensure Our Seniors are Staying Hydrated this Summer:

  • Monitor fluid intake
  • Act on reports of persistent fatigue, muscle weakness, headaches, dizziness
  • Encourage residents to drink during meals and throughout the day
  • Takes multiple sips of liquid between bites of food
  • Consume water with medications
  • Intake fluids after toilet use
  • When residents refuse to drink offer different forms of liquids such as popsicles, soup, melon, strawberries, or watermelon
  • Keep water nearby for easy access
  • Start a “sip and go” program that encourages residents to hydrate before participating in activities or therapy

Did You Know that Encore has a Hydration Program?

Encore’s Hydration program identifies residents who may be at risk for dehydration, may have difficulty with oral intake, and individuals who would benefit from advancement in diet texture and assurance of safe swallow.  

The Hydration Program involves interdisciplinary team members working together to enrich each resident’s quality of life and maintain high health and wellness levels.

Be sure to connect with your therapy team today to begin the Hydration Program at your location.


Improving Access to Medicare Coverage Act of 2021 (S.2048) Reintroduced

Per CMS, communal activities and dining may begin to On 6/15/2021, U.S. Senators Sherrod Brown (D-OH), Susan Collins (R-ME), Sheldon Whitehouse (D-DI), and Shelley Moore Capito (R-WV) reintroduced their bipartisan legislation, the Improving Access to Medicare Coverage Act of 2021 (S.2048).  This is the Senate companion bill to U.S. Representative Joe Courtney’s (D-CT) bipartisan bill that would count the days that a Medicare beneficiary spends in the hospital under observation towards the three-day hospital inpatient stay requirement for skilled nursing care. Specifically, the Senate bill would:
  • Amend Medicare law to count a beneficiary’s time spent in the hospital on “observation status” towards the three-day hospital stay requirement for skilled nursing care; and
  • Establish a 90-day appeal period following passage for those that have a qualifying hospital stay and have been denied skilled nursing care after January 1, 2021

Eyes Our For Proposed and Final Rules:

SNF PPS Proposed Rule Comments had to be Submitted by June 7th
  • Final Rule Expected end of July Physician Fee Schedule Proposed Rule
  • Typically released around 4th of July but last year was delayed until August, and final rule released 12/1/20

Recent Avalere Report Issued in Response to CMS' Proposed Parity Rate Adjustment

The Centers for Medicare & Medicaid Services must consider the COVID-19 pandemic’s broad impact on the skilled nursing patient population and the resulting effect it had on Medicare payments for SNF care before toying with PDPM rates, asserts a new Avalere Health analysis. 



Rehab Round Table
Quality of Life Program
Learning Objectives:
  1. Impact of a Quality of Life Program
  2. 5-Star Rating Influence Through IDT Team 
  3. Program Training
  4. Facility and Community Networking  
  5. Client-Centered Census Development


CPT 97110 has been the subject of recent TPEs by the MACs. Take the time toreview this refresher on CPT 97110, therapeutic exercise. 
If an exercise is taught to a patient and performed to restore functional strength, range of motion, endurance training, and flexibility, CPT code (97110) is the appropriate code. If the focus is not strength, range of motion, endurance or flexibility, then it is likely that a different CPT code is more appropriate. 

Therapeutic exercises are used to restore strength, endurance, range of motion and flexibility where loss or restriction is a result of a specific disease or injury and has resulted in a functional limitation. Documentation should include measurable indicators to support the medical necessity of therapeutic exercises such as functional loss of joint motion or muscle strength and  information on the impact of these limitations on the patient’s life and how improvement in one or more of these measures leads to improved function. The prescription for the resistance, repetitions, and sets should be individualized, and if for strength, no more than 2-3x/week. 

Many therapeutic exercises require the unique skills of a therapist to evaluate the patient’s abilities, design the program, and instruct the patient or caregiver in safe completion of the special technique. However, after the teaching has been successfully completed, repetition of the exercise, and monitoring for the completion of the task, in the absence of additional skilled care, is non-covered. Repetitive type exercises often can be taught to the patient or a caregiver as part of a self-management, caregiver or nursing program. For example, NGS’ LCD 26884 Outpatient Physical and Occupational Therapy Services states that “for many patients, a passive-only exercise program should not be used more than 2-4 visits to develop and train the patient or caregiver in performing PROM.” Exercises to promote overall fitness, flexibility, endurance (in the absence of a complicated patient condition), aerobic conditioning, weight reduction, and maintenance exercises to maintain range of motion and/or strength are non-covered. In addition, exercises that do not require, or no longer require, the skilled assessment and intervention of a qualified professional/auxiliary personnel are non-covered. 

NGS’ LCD 26884 Outpatient Physical and Occupational Therapy Services provides the following example of when a service that is initially skilled becomes non-skilled: “as part of the initial therapy program following total knee arthroplasty (TKA), a patient may start a session on the exercise bike to begin gentle range of motion activity. Initially, the patient requires skilled progression in the program from pedal-rocks, building to full revolutions, perhaps assessing and varying the seat height and resistance along the way. Once the patient is able to safely exercise on the bike, no longer requiring frequent assessment and progression, even if set up is required, the bike now becomes an “independent” program and is no longer covered by Medicare. While the qualified professional/auxiliary personnel may still require the patient to “warm-up” on the bike prior to other therapeutic interventions, it is considered a non-skilled, unbillable service and should not be included in the total timed code treatment minutes.”

Supportive Documentation Recommendations for 97110: 

  • Objective measurements of loss of strength and range of motion (with comparison to the uninvolved side) and effect on function
    • Pt will increase right ankle DF ROM from -5 degrees to 15 degrees to normalize gait terminal stance and decrease early heel off and decrease excessive hip flexion compensation during swing leg advancement
    • Patient will increase left hip abduction strength from 2/5 to 4/5 to prevent right pelvis drop during right swing phase
  • If used for pain, include pain rating, location of pain, effect of pain on function
  • Analysis of substitutions
    • AROM rt. Shoulder. Verbal and manual cueing during right shoulder flexion and abduction to correct shoulder elevation/hiking substitution
  • Progressions/Downgrades
    • Progressed patient from supine hip abduction to sidelying hip abduction with knee bent to decrease lever arm. Will progress to straight knee as strength improves.
  • Techniques used to ensure proper performance
    • LE progressive resistive exercises. Focus on side-lying hip abduction performed with manual resistance to hip extension during abduction to decrease hip flexor substitution pattern and increase hip abduction strength
  • Instruction in HEP or caregivers
  • Emphasize why therapist was important in therapeutic exercise
    • May include skilled cardiopulmonary monitoring including documentation of pulse oximetry, heart rate, blood pressure, perceived exertion, etc.



MACs Resume Medical Review on a Post-Payment Basis

August 2020, Medicare Administrative Contractors (MACs) resumed post-payment reviews of items and services with dates of service before March 2020. MACs may now begin conducting post-payment medical reviews for later dates of service (after March 2020). The Targeted Probe and Educate program (intensive education to assess provider compliance through up to 3 rounds of review) will restart later. The MACs will continue to offer detailed review decisions and educationas appropriate.


For more information:
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