Article for Swallow Evaluation and Dysphagia Treatment – Supplemental Instructions Article (A47391)


Contractor Information

 
Contractor Name 
National Government Services, Inc.  
Contractor Number 
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
Contractor Type 
Carrier
Fiscal Intermediary
MAC – Part A
MAC- Part B


Article Information

 
Article ID Number 
A47391 
Article Type 
Article
Key Article 
Yes
Article Title 
Swallow Evaluation and Dysphagia Treatment – Supplemental Instructions Article 
AMA CPT / ADA CDT Copyright Statement 
CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association.© 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
 
Primary Geographic Jurisdiction 
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
Original Article Effective Date 
11/15/2008
Article Revision Effective Date 
12/01/2010
Article Text 
The information in this Supplemental Instructions Article (SIA) contains coding or other guidelines that complement the Local Coverage Determination (LCD) for Swallow Evaluation and Dysphagia Treatment. The LCD can be accessed through our contractor Web site at www.NGSMedicare.com. It can also be found on the Medicare Coverage Database at www.cms.gov/mcd.

Coding Guidelines:

General Guidelines for claims submitted to carriers or intermediaries or Part A or Part B MAC:


Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-9-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known, otherwise the symptoms prompting the performance of the test should be reported.

Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Fiscal Intermediary (FI) and Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Fiscal Intermediary or Part A MAC, occurrence code 32 and the date of the ABN is required.

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, FI and Part A MAC systems will automatically deny the services.

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary.

‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

CPT code 92610 may be reported when the medical record indicates that a non-instrumental clinical examination has been performed, but this code may not be billed more than once on a patient per day.

Fiberoptic Endoscopic Evaluation of Swallowing (FEES) will incorporate both the placement of the flexible fiberoptic laryngoscope and the evaluation of swallowing and oral function for feeding. The CPT code reported on the claim should be 92612. This CPT code encompasses the entire procedure and should not be billed more than one time on the same patient on the same day.

Fluoroscopy codes 76000 and 76001 are not allowed in addition to a swallow study.

CPT codes 92526 and 97150 should not be billed on the same date of service.

Swallow evaluations (CPT codes 92610, 92611, 92612, 92614 and 92616) may be performed by physicians, speech-language pathologists or occupational therapists. Under the Medicare Program, an independently practicing speech pathologist may now bill the Medicare program directly. Section 143 of the Medicare Improvements for Patients and Provider's Act of 2008 (MIPPA) authorizes the Centers for Medicare & Medicaid Services (CMS) to enroll speech-language pathologists (SLP) as suppliers of Medicare services and for SLPs to begin billing Medicare for outpatient speech-language pathology services furnished in private practice beginning July 1, 2009. Enrollment will allow SLPs in private practice to bill Medicare and receive direct payment for their services. Previously, the Medicare program could only pay SLP services if an institution, physician or nonphysician practitioner billed them. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10).

However, the services of speech-language pathologists may continue to be billed by providers such as rehabilitation agencies, HHAs, CORFs, hospices, outpatient departments of hospitals, and suppliers such as physicians, non-physician practitioners (NPPs), physical and occupational therapists in private practice. When these services are billed by physicians or NPPs, they are covered when billed under the "incident to" provision. "Incident to" services or supplies are defined as those furnished as an integral, although incidental, part of the physician's or NPPs personal professional services in the course of diagnosis or treatment of an injury or illness. These services must be related directly and specifically to a written treatment regimen established by the physician/NPP, after any needed consultation with a qualified speech pathologist, or by the speech pathologist providing such services.

Providers must use modifier -GN to identify service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology Plan of Care. (See CMS Publication. 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.1)

Effective January 1, 2006, a financial limitation (therapy cap) was placed on outpatient rehabilitation services received by Medicare beneficiaries. These limits apply to outpatient Part B therapy services from all settings except the outpatient hospital (place of service code 22 on carrier claims) and the hospital emergency room (place of service code 23 on carrier claims). These excluded hospital services are reported on types of bill 12x or 13x on intermediary claims. The annual limit on the allowed amount is combined for outpatient physical therapy and speech-language pathology. For more information on the therapy cap, see: CMS publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10.2.

A process to allow for exceptions to the caps has been established in cases where continued therapy services are medically necessary. Exceptions to caps based on the medical necessity of the service are in effect only when Congress legislates the exceptions. References to the exceptions process apply only when the exceptions are in effect. The KX modifier is added to claim lines to indicate that the clinician attests that services are medically necessary and justification is documented in the medical record.

Units of Service
When a therapy treatment modality or procedure is not defined by a specific time frame (such as "each 15 minutes"), the modality or procedure is considered an "untimed" service. Untimed services are billed once per day. Untimed services billed as more than "1" unit will be denied, and upon appeal will require significant documentation to justify treatment greater than one session per day per therapy discipline.

Based on CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.2(D), CPT codes 92611, 92612, 92614 and 92616 may be billed no more than one unit, per provider, per discipline, per date of service, per patient.

For claims submitted to the carrier or Part B MAC:

Claims for swallow evaluation and dysphagia treatment services (CPT codes 92610, 92611, 92612, 92613, 92614, 92615, 92616 and 92617) are payable to those qualified professionals who are permitted to bill under Medicare Part B in the following places of service:

Office (11), inpatient hospital (21), outpatient hospital (22), emergency room (23), ambulatory surgical center (24), skilled nursing facility (31) nursing facility (32) and independent clinic (49).

CPT codes 92613, 92615 or 92617 describe a physician's review and interpretation of the fiberoptic flexible endoscopic evaluation performed by another provider. These codes may be billed separately provided they represent a separately identified physician review and interpretation of the fiberoptic endoscopic evaluation.

For claims submitted to the fiscal intermediary or Part A MAC:

Hospital Inpatient Claims:
  • The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
  • The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.
  • For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)
Hospital Outpatient Claims:
  • The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient’s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82).
  • The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.


Coding Information

 
Bill Type Codes: 

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
034x Home Health - Other (for medical and surgical services not under a plan of treatment)
074x Clinic - Outpatient Rehabilitation Facility (ORF)
075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
085x Critical Access Hospital
 
Revenue Codes: 

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the article services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.

032X Radiology - Diagnostic - General Classification
0430 Occupational Therapy - General Classification
0434 Occupational Therapy - Evaluation or Reevaluation
0440 Speech Therapy - Language Pathology - General Classification
0444 Speech Therapy - Language Pathology - Evaluation or Reevaluation
0750 Gastro-Intestinal (GI) Services - General Classification
096X Professional Fees - General Classification
0971 Professional Fees - Laboratory
0972 Professional Fees - Radiology - Diagnostic
0973 Professional Fees - Radiology - Therapeutic
0974 Professional Fees - Radiology Nuclear
0975 Professional Fees - Operating Room
0976 Professional Fees - Respiratory Therapy
0977 Professional Fees - Physical Therapy
0978 Professional Fees - Occupational Therapy
0979 Professional Fees - Speech Pathology
0981 Professional Fees - Emergency Room Services
0982 Professional Fees - Outpatient Services
0983 Professional Fees - Clinic
0984 Professional Fees - Medical Social Services
0985 Professional Fees - EKG
0986 Professional Fees - EEG
0987 Professional Fees - Hospital Visit
0988 Professional Fees - Consultation
0989 Professional Fees - Private Duty Nurse
 
CPT/HCPCS Codes 

92526 TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING
92610 EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION
92611 MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY CINE OR VIDEO RECORDING
92612 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING BY CINE OR VIDEO RECORDING;
92613 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING BY CINE OR VIDEO RECORDING; PHYSICIAN INTERPRETATION AND REPORT ONLY
92614 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION, LARYNGEAL SENSORY TESTING BY CINE OR VIDEO RECORDING;
92615 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION, LARYNGEAL SENSORY TESTING BY CINE OR VIDEO RECORDING; PHYSICIAN INTERPRETATION AND REPORT ONLY
92616 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING AND LARYNGEAL SENSORY TESTING BY CINE OR VIDEO RECORDING;
92617 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING AND LARYNGEAL SENSORY TESTING BY CINE OR VIDEO RECORDING; PHYSICIAN INTERPRETATION AND REPORT ONLY
92700 UNLISTED OTORHINOLARYNGOLOGICAL SERVICE OR PROCEDURE
97150 THERAPEUTIC PROCEDURE(S), GROUP (2 OR MORE INDIVIDUALS)
 
ICD-9 Codes that are Covered 
Please see LCD.
 
ICD-9 Codes that are Not Covered 
Not applicable
 


Other Information

 
Other Comments 
These supplemental instructions apply within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims.
Revision History Explanation 
Article published December 2010: Based on instructions in CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230, the following coding guideline was added:

CPT codes 92526 and 97150 should not be billed on the same date of service.

Added CPT code 97150 to the “CPT/HCPCS Codes” section.

Minor template changes were made to reflect current template language.


Article published June 2010: Limitation of liability guidelines revised in accordance with CMS Transmittals 1840 and 1921.

Minor template changes were made to reflect current template language.

Article published July 2009: Source of revision – Internal: Based on CMS Transmittal No. 106, Publication 100-02, Medicare Benefit Policy Manual, Change Request #6381, April 24, 2009 and CMS Transmittal No. 1717, Publication 100-04, Medicare Claims Processing Manual, Change Request #6381, April 24, 2009, the following paragraphs were added to the "Coding Guidelines" section:

Swallow evaluations (CPT codes 92610, 92611, 92612, 92614 and 92616) may be performed by physicians, speech-language pathologists or occupational therapists. Under the Medicare Program, an independently practicing speech pathologist may now bill the Medicare program directly. Section 143 of the Medicare Improvements for Patients and Provider's Act of 2008 (MIPPA) authorizes the Centers for Medicare & Medicaid Services (CMS) to enroll speech-language pathologists (SLP) as suppliers of Medicare services and for SLPs to begin billing Medicare for outpatient speech-language pathology services furnished in private practice beginning July 1, 2009. Enrollment will allow SLPs in private practice to bill Medicare and receive direct payment for their services. Previously, the Medicare program could only pay SLP services if an institution, physician or nonphysician practitioner billed them. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10).

However, the services of speech-language pathologists may continue to be billed by providers such as rehabilitation agencies, HHAs, CORFs, hospices, outpatient departments of hospitals, and suppliers such as physicians, non-physician practitioners (NPPs), physical and occupational therapists in private practice. When these services are billed by physicians or NPPs, they are covered when billed under the "incident to" provision. "Incident to" services or supplies are defined as those furnished as an integral, although incidental, part of the physician's or NPPs personal professional services in the course of diagnosis or treatment of an injury or illness. These services must be related directly and specifically to a written treatment regimen established by the physician/NPP, after any needed consultation with a qualified speech pathologist, or by the speech pathologist providing such services.

Minor template changes were made to reflect current template language.

06/05/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number 00270 was removed from this article as the claims processing for New Hampshire and Vermont was transitioned to NHIC, the Part A/Part B MAC contractor in these states.

05/15/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary numbers 00180 and 00181 were removed from this Article as the claims processing for Maine and Massachusetts was transitioned to NHIC, the Part A/Part B MAC contractor in these states.

Article published November 2008

8/1/2010 - The description for Bill Type Code 11 was changed
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 21 was changed
8/1/2010 - The description for Bill Type Code 22 was changed
8/1/2010 - The description for Bill Type Code 23 was changed
8/1/2010 - The description for Bill Type Code 34 was changed
8/1/2010 - The description for Bill Type Code 74 was changed
8/1/2010 - The description for Bill Type Code 75 was changed
8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0320 was changed
8/1/2010 - The description for Revenue code 0321 was changed
8/1/2010 - The description for Revenue code 0322 was changed
8/1/2010 - The description for Revenue code 0323 was changed
8/1/2010 - The description for Revenue code 0324 was changed
8/1/2010 - The description for Revenue code 0329 was changed
8/1/2010 - The description for Revenue code 0430 was changed
8/1/2010 - The description for Revenue code 0434 was changed
8/1/2010 - The description for Revenue code 0440 was changed
8/1/2010 - The description for Revenue code 0444 was changed
8/1/2010 - The description for Revenue code 0750 was changed
8/1/2010 - The description for Revenue code 0960 was changed
8/1/2010 - The description for Revenue code 0961 was changed
8/1/2010 - The description for Revenue code 0962 was changed
8/1/2010 - The description for Revenue code 0963 was changed
8/1/2010 - The description for Revenue code 0964 was changed
8/1/2010 - The description for Revenue code 0969 was changed
8/1/2010 - The description for Revenue code 0971 was changed
8/1/2010 - The description for Revenue code 0972 was changed
8/1/2010 - The description for Revenue code 0973 was changed
8/1/2010 - The description for Revenue code 0974 was changed
8/1/2010 - The description for Revenue code 0975 was changed
8/1/2010 - The description for Revenue code 0976 was changed
8/1/2010 - The description for Revenue code 0977 was changed
8/1/2010 - The description for Revenue code 0978 was changed
8/1/2010 - The description for Revenue code 0979 was changed
8/1/2010 - The description for Revenue code 0981 was changed
8/1/2010 - The description for Revenue code 0982 was changed
8/1/2010 - The description for Revenue code 0983 was changed
8/1/2010 - The description for Revenue code 0984 was changed
8/1/2010 - The description for Revenue code 0985 was changed
8/1/2010 - The description for Revenue code 0986 was changed
8/1/2010 - The description for Revenue code 0987 was changed
8/1/2010 - The description for Revenue code 0988 was changed
8/1/2010 - The description for Revenue code 0989 was changed

8/1/2010 - Revenue code 0759 was deleted
 
Related Documents 
LCD(s)
L27364 - Swallow Evaluation and Dysphagia Treatment