Determining the safest and least restrictive diet for individuals with difficulty swallowing or dysphagia can be a complex process to navigate. Considerations include the need to maintain adequate intake for nutrition and hydration while keeping individuals safe from the risks of aspiration and honoring individuals’ wishes — a complicated and tall order.

Presently, we as interdisciplinary teams know that collaboration is key from a clinical perspective.

Making these decisions requires insight from multiple members of the interdisciplinary team, with the patient being central and including the family, doctor, nursing teams, social services and rehab professionals, including, physical, occupational and speech therapists.

With the forthcoming implementation of the Patient-Driven Payment Mode, collaboration will be needed from a clinical and reimbursement perspective since specific areas of MDS Section K are determiners for the speech pathology case mix.

Furthermore, the final rule clarifies that the Centers for Medicare & Medicaid Services will monitor any increases in the use of mechanically altered diet among the SNF population that may suggest that beneficiaries are being prescribed such a diet based on facility financial considerations, rather than for clinical need.

Coding accuracy will be essential.

So, what do we all need to know about swallow function?

  1. How does Medicare define dysphagia?

To begin, Medicare defines dysphagia in Chapter 15 of the Benefit Policy Manual as “difficulty in swallowing, which can cause food to enter the airway, resulting in coughing, choking, pulmonary problems, aspiration, or inadequate nutrition and hydration with resultant weight loss, failure to thrive, pneumonia, and death. Most often due to complex neurological and/or structural impairments, including head and neck trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, dementias, and encephalopathies.”

For these reasons, Medicare says that it is important that only qualified professionals with specific training and experience in this disorder provide evaluation and treatment.

  1. What areas of MDS Section K will impact the speech pathology case mix under PDPM?

Section K: Swallowing and Nutritional Status

  • K0100A Loss of liquids/solids from mouth when eating or drinking

  • K0100B Holding food in mouth/cheeks or residual food in mouth after meals

  • K0100C Coughing or choking during meals or when swallowing medications

  • K0100D Complaints of difficulty or pain with swallowing

  • K0100Z None of the above

  • K0510C2 Mechanically Altered Diet While a Resident

  1. What would a speech language pathologist want you to know about the swallowing process?

Swallowing is a complex process involving four specific phases: oral preparatory, oral, pharyngeal and esophageal.

In the oral preparatory phase, food enters the oral cavity requiring adequate labial (lip) strength to hold the bolus (i.e. food or liquid) in the mouth. Then lingual (tongue) strength, in conjunction with rotary movements of the jaw (mastication/chewing), hold the bolus in place until an adequate solid and cohesive form is made.

In the oral phase of swallowing, the tongue begins anterior to posterior movements while holding the food bolus (like a cup) to the back of the tongue, then the base (back) of the tongue rises and the bolus begins its descent into the pharynx (throat).

During the pharyngeal phase, the soft palate elevates to contact the posterior pharyngeal wall and the larynx (voice box) elevates toward the base of tongue, bringing a passive flipping over of the epiglottis to cover the opening to the larynx and trachea.

Next, the muscles in the pharynx contract, moving the bolus downward toward the opening of cricopharyngeal sphincter (muscle at the top of the food tube) to allow passage of the bolus into the esophagus. During the esophageal phase, which is the final phase of the swallow, the cricopharyngeus muscle relaxes and the bolus passes into the esophagus. A rapid peristaltic (wavelike) contraction travels behind the bolus to clear it into the stomach.

  1. What should team members consider as signs of difficulty swallowing to help guide Section K coding?

Oral Preparatory Phase Impairment Signs

  • Anterior loss (spillage of food or liquid bolus) from the lips;

  • Food particles on the lips during intake;

  • Decreased ability to clear food from a spoon due to weak lips;

  • Food and liquid remaining in the anterior and lateral sulci (the pocket in front teeth and behind lips and between teeth and cheeks);

  • Limited tongue movement side to side;

  • Munching chewing pattern (up and down) versus rotary chewing pattern (circular movements); and

  • Documented impairment in MDS (Minimum Data Set) Section K0100A: loss of liquids/solids from mouth when eating or drinking.

Oral Phase Impairment Signs

  • Decreased lingual (tongue) movements front to back;

  • Decreased rise of back of the tongue to begin the next phase of swallow (pharyngeal phase), resulting in food remaining on the back of the tongue; and

  • Documented impairment in MDS Section K0100B: holding food in mouth/cheeks or residual food in mouth after meals.

Pharyngeal Impairment Signs

  • Delayed swallow start. Look for the back of the tongue “pumping” up and down (however, it takes multiple pumps to swallow);

  • Non-overt signs and symptoms, including shortness of breath with meals. Often the geriatric population presents with decreased sensory awareness. Therefore, cough reflex and the natural reflex to clear throat when food is hanging in pharynx (throat) may be reduced);

  • Overt signs and symptoms including throat clearing with intake — before, during, or after the swallow; and coughing with intake —before, during, or after the swallow; and

  • Documented impairment in MDS Section K0100C: coughing or choking during meals or when swallowing medications.

Esophageal Impairment Signs

  • Patient complains of a “lump in the throat;”

  • Odynophagia, or painful swallowing;

  • Increased difficulty with swallowing ~30 minutes into a meal;

  • Oral and/or nasal regurgitation;

  • Signs following periods of decreased head elevation, including increased need to clear throat or increased phlegm in the morning;

  • Complaints of heartburn or reflux; and

  • Documented impairment in MDS Section K0100D: complaints of difficulty or pain with swallowing.

In closing, understanding and coding accurately for Section K should not be a hard task to swallow. Teams should begin the process now to promote precision and ensure successful coding practices in the year to come.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Director of Clinical Education for Encore! Rehabilitation Services  and is the Silver Award winner in the 2018 American Society of Business Publishing Editors competition for the Upper Midwest Region in the Service/How To Blogs category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).