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How to Speak the Same Language for Section K Coding: NACs and SLPs

When a nurse assessment coordinator (NAC) reviews the speech language pathologist (SLP) evaluation notes and encounters the term globus sensation, he or she may not even consider that the phrase could indicate a potential swallowing problem. While the NAC and SLPoften work toward the same goals of identifying possible swallowing and speech problems, the terminology SLPs use may not be clear to NACs. Collaboration between the SLP and the NAC is vital to appropriately identify and communicate potential problems, capture those concerns on the MDS, and address them in the resident’s care plan. The following four tips will help the NAC and SLP “speak the same language” to improve collaboration and increase MDS accuracy.

Foster a team approach to share information and improve communication

A NAC who does not have access to SLP documentation doesn’t know what he or she could be missing for MDS coding, points out Megan Ussery, RN, RAC-CT, director of clinical reimbursement with Quality Rehab Management (QRM). “Supporting documentation may be missed because NACs did not have access to the SLP documentation or did not know where to find it.”

However, once the NAC and SLP have coordinated to either allow access to the electronic medical record (EMR) or share the SLP documentation in another way, the NAC must also communicate to the SLP what is needed to support the MDS. Ussery adds, “Providing the SLP with a copy of the coding instructions for K0100A-D will help the therapist understand exactly what the MDS assessment captures and what signs and symptoms of possible swallowing disorders should be shared with the NAC and clinical team.”

The RAI User’s Manual provides the following coding instructions for K0100A-D.  

  • K0100A, loss of liquids/solids from mouth when eating or drinking. When the resident has food or liquid in his or her mouth, the food or liquid dribbles down chin or falls out of the mouth.

  • K0100B, holding food in mouth/cheeks or residual food in mouth after meals. Holding food in mouth or cheeks for prolonged periods of time (sometimes labeled pocketing) or food left in mouth because resident failed to empty mouth completely.

  • K0100C, coughing or choking during meals or when swallowing medications. The resident may cough or gag, turn red, have more labored breathing, or have difficulty speaking when eating, drinking, or taking medications. The resident may frequently complain of food or medications “going down the wrong way.”

  • K0100D, complaints of difficulty or pain with swallowing. Resident may refuse food because it is painful or difficult to swallow.

Ussery also emphasizes that assessment and documentation of possible swallowing disorders is not the sole responsibility of the SLP. Nurses must be trained to monitor and assess for signs and symptoms of possible swallowing disorders, and direct care staff must be educated to monitor and report possible swallowing problems to the charge nurse. “Some facilities take advantage of their EMR and provide cues for nurse aides to electronically report any observations of specific signs, such as loss of liquids or solids from mouth when eating or drinking,” notes Ussery.

Additionally, Ussery stresses the importance of a team approach to monitor and identify these problems, “If occupational therapy is working on feeding—what are they seeing? Educate all therapists, not just the SLP, to document observed symptoms and communicate these findings with the NAC and clinical team.”

Establish common ground for SLP-specific terminology

The NAC may not use SLP-specific terminology on a daily basis, so sometimes the SLP must provide clarification to ensure common understanding and support accurate MDS coding.

For example, Globus sensation is a term that the NAC may see on an SLP evaluation; it means an overwhelming feeling of a lump or foreign object being lodged in a person’s throat. However, a physical examination will reveal there is no object or lump present (Fletcher, 2017).

When the SLP evaluation or notes identify globus sensation, the NAC should further vet the issue to understand if any signs or symptoms of possible swallowing programs are present. For example, the NAC should ask, “What led to the SLP determination that globus sensation was present? Did the resident complain of difficulty swallowing?”

Then, the SLP should review the signs and symptoms that are included in the MDS. By choosing simpler terminology in the evaluation or treatment notes, the SLP can clarify exactly what he or she observed. A small adjustment in terminology can help to support the coding of K0100, not only for the NAC, but also during a medical review.

Ussery encourages NACs to ask the SLP what a specific term indicates if they do not fully understand the SLP documentation. “Often, there are terms used in the SLP documentation that, as a nurse, I could guess to what it means, but it is very important to understand what it means to the SLP. For example, anterior spillage, which simply is the leakage of food from the mouth, is also a symptom of dysphagia (oral prep and oral phase) being assessed by the SLP,” notes Ussery. This should lead to a conversation about whether an appropriate diagnosis for dysphagia is in place and working with the physician regarding these findings.

Take advantage of team meetings

A separate meeting is not always needed to communicate SLP-related concerns. Ussery suggests that communication “Starts with a strong morning meeting, discussing who is on SLP caseload, and then holding weekly meetings (Medicare, skilled, utilization-type meetings) where the team can really dig in and talk about why the resident is on caseload, what are they treating, what does the documentation look like.” Ussery explains that these meetings provide an opportunity to ensure the documentation accurately reflects the residents’ conditions and supports the coding for the MDS.

Often, several facilities share a single SLP, and it may not be feasible to have the SLP present in each meeting. It is critical that the therapy lead also be well-versed in the MDS requirements and help to communicate findings to SLP.

Additionally, Ussery encourages SLPs to take advantage of the EMR the facility uses. “For example, if the facility has set up a user-defined assessment (UDA) to assess or observe the presence of swallowing problems, the SLP could access this documentation for more information when they are unable to attend facility meetings.”

Maintain focus on why this information is important

“The reason we assess possible signs and symptoms of swallowing problems is because of the risk associated with these problems,” stresses Ussery. “These symptoms should alert the team that there is a potential problem we need to pay more attention to.” Ussery emphasizes that while the Patient-Driven Payment Model (PDPM) methodology uses K0100, the fact that the symptom increases reimbursement is not the reason it’s coded. “The reimbursement allows the team to pour resources into these risk factors, such as providing speech therapy and implementing interventions to mitigate the resident’s risk and to achieve resident safety by preventing adverse events, aspiration, or hospitalization.” This is also why the NAC codes K0100, even if the symptom only occurs one time in the look-back period, Ussery points out. “Even if a symptom is only identified once, it warrants the assessment and investigation to identify the risk, initiate an SLP screen or evaluation as indicated, and implement appropriate interventions. The only way to reduce the risk is by investing the resources into the assessment, ensuring that the MDS is coded accurately, and thoroughly assessing the potential problem through the care areas and addressing it in the care plan.”


Fletcher, J. (2017, December 5). Globus sensation: Causes of a lump in the throat. Medical News Today. https://www.medicalnewstoday.com/articles/320245

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