Language quoted from Centers for Medicare
and Medicaid Services (CMS), National Coverage Determinations (NCDs)
and coverage provisions in interpretive manuals is italicized
throughout the policy. NCDs and coverage provisions in interpretive
manuals are not subject to the Local Coverage Determination (LCD)
Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In
addition, an administrative law judge may not review an NCD. See
Section 1869(f)(1)(A)(i) of the Social Security Act.
Unless
otherwise specified, italicized text represents quotation
from one or more of the following CMS sources:
Title XVIII
of the Social Security Act (SSA):
Section 1862(a)(1)(A)
excludes expenses incurred for items or services which are not
reasonable and necessary for the diagnosis or treatment of illness
or injury or to improve the functioning of a malformed body
member.
Section 1833(e) prohibits Medicare payment for any
claim which lacks the necessary information to process the claim.
Code of Federal Regulations:
42 CFR Section
410.32, indicates that diagnostic tests may only be ordered by the
treating physician (or other treating practitioner acting within the
scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a
specific medical problem and who uses the results in the management
of the beneficiary's specific medical problem. Tests not ordered by
the physician (or other qualified non-physician provider) who is
treating the beneficiary are not reasonable and necessary (see Sec.
411.15(k)(1) of this chapter).
CMS Transmittal No. 111, Publication
100-02, Medicare Benefit Policy Manual, Change Request #6005,
September 25, 2009, advises that speech-language pathology therapy
services are covered CORF services if physical therapy services are
the predominate rehabilitation services.
CMS Transmittal No.
106, Publication 100-02, Medicare Benefit Policy Manual,
Change Request #6381, April 24, 2009, advises that enrolled
speech-language pathologists may bill for services provided on or
after July 1, 2009.
CMS Transmittal No. 1717, Publication
100-04, Medicare Claims Processing Manual, Change Request
#6381, April 24, 2009, advises that enrolled speech-language
pathologists may bill for services provided on or after July 1,
2009.
Primary Geographic Jurisdiction
Number
Type
State(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
Oversight Region
Region I, II, III, V
Region V
Original Determination
Effective Date
For services performed on or after
11/15/2008
Original Determination
Ending Date
Revision Effective
Date
For services performed on or after
12/01/2010
Revision Ending
Date
Indications and Limitations
of Coverage and/or Medical Necessity
Abstract:
Dysphagia, or
difficulty in swallowing, can cause solids or liquids to enter the
airway, resulting in coughing, choking, aspiration, or inadequate
nutrition and hydration with resultant weight loss, failure to
thrive, pneumonia, and death. Dysphagia is a swallowing disorder
that may be due to various neurological, structural or cognitive
deficits, and deconditioning. It may be the result of head and neck
trauma, cerebrovascular accident, neuromuscular degenerative
diseases, head and neck cancer and related treatment, as well as
encephalopathies. Dysphagia most often reflects problems involving
the oral cavity, pharynx, esophagus, gastroesophageal junction, or
proximal stomach. While dysphagia can afflict any age group, it most
often appears among the elderly. Speech-language pathology services
are covered under Medicare for the treatment of dysphagia,
regardless of the presence of a communication disability.
Patients who are motivated, moderately alert, and have some
capacity for deglutition and swallowing are appropriate candidates
for dysphagia therapy. Elements of the therapy program can include
thermal stimulation to heighten the sensitivity of the swallowing
reflex, exercises to improve oral-motor control and laryngeal
elevation training in laryngeal adduction and compensatory
swallowing techniques, and positioning and dietary modifications.
All programs are designed to ensure swallowing safety during oral
feedings and maintenance of adequate
nutrition.
Indications and
Limitations:
Dysphagia Categories
Oral,
pharyngeal, or upper esophageal dysphagia Oral dysphagia is
defined as an inability to coordinate chewing and swallowing a bolus
of solids or liquids placed in the mouth. The oral stage of
swallowing involves the lips, jaw, tongue, and soft palate to
prepare the bolus for swallowing and to transport the bolus into the
pharynx. Muscular weakness or incoordination, lack of sensation, or
alteration of these structures can result in an inefficient and
prolonged oral stage that leaves residue in the mouth, or can result
in all bolus types spilling prematurely into the
pharynx.
Pharyngeal dysphagia is defined as an impairment of
strength, timing, and/or coordination to propel a bolus through the
pharynx into the esophagus while closing off the entrance to the
larynx during the act of swallowing.
The pharyngoesophageal
phase of swallowing (upper one-third of the esophagus) involves the
passage of a bolus through the upper esophageal sphincter, into the
esophagus, and through the lower sphincter into the stomach.
Esophageal dysphagia is primarily addressed through medical
assessment and management. Speech-language pathologists and
qualified occupational therapists may be involved in evaluation of
the upper third of the esophagus for esophageal motility and
gastroesophageal reflux and provide counseling and
exercises.
Lower esophageal phase of dysphagia The
esophageal (lower two thirds) phase of swallowing is associated with
difficulty in passing food from the esophagus to the stomach. If
peristalsis is inefficient, patients may complain of food getting
stuck or of having more difficulty swallowing solids than liquids.
Sometimes patients experience esophageal reflux or regurgitation,
especially if they lie down too soon after meals.
Inefficient
functioning of the esophagus during the esophageal phase of
swallowing is a common problem in the geriatric patient. Swallowing
disorders occurring only in the lower two thirds of the esophageal
stage of the swallow are usually not amenable to swallowing therapy
techniques.
Professional
Qualifications
Swallowing assessment and
rehabilitation are highly specialized services. The professional
rendering care must have education, experience and demonstrated
competencies. Competencies include but are not limited to:
identifying abnormal upper aerodigestive tract structure and
function; conducting an oral, pharyngeal, laryngeal and respiratory
function examination as it relates to the functional assessment of
swallowing; recommending methods of oral intake and risk
precautions; and developing a treatment plan employing appropriate
compensations and therapy techniques.
A skilled therapist
refers to a speech-language pathologist, occupational therapist,
physician, or nonphysician practitioner (NPP) who is licensed,
certified, or otherwise authorized by the state to perform therapy
services. The services of speech-language pathology assistants are
not recognized as skilled therapy services and are not covered by
Medicare.
SWALLOWING EVALUATION
Evaluation of
Oral and Pharyngeal Swallowing Function (CPT Code
92610)
An evaluation of the patient's swallowing
mechanism may include a clinical bedside evaluation of swallowing,
evaluation of oral-motor functioning, and/or instrumental
assessment.
Clinical bedside examination consists of a
pertinent medical history, careful examination of the lip function,
tongue function, soft palate function, responses to oral
sensitivity, and determination of the patient's memory, ability to
follow directions and participate in therapy. If the bedside
examination indicates that the patient may have a pharyngeal
dysfunction or is at risk for aspiration, then additional evaluation
with an instrumental assessment may be needed. The clinician's
clinical assessment should document history, diagnosis, current
eating and nutritional status, behavioral and cognitive status,
pertinent clinical observations including oral functioning
(swallowing positioning and general articulation), and signs and
symptoms of possible dysphagia.
Instrumental
Assessments Used to Study Swallowing (CPT Codes 92611, 92612, 92614,
92616, and 92700)
Instrumental assessment of
swallowing may be indicated for the evaluation of a patient with
dysphagia, who has a pharyngeal dysfunction or who is at risk for
aspiration.
Examples of clinical syndromes where instrumental
assessment of swallowing may be indicated are:
Stroke or other central nervous system (CNS) disorder with
associated impairment of speech and swallowing;
Difficulty swallowing following surgical ablation, radiation,
or chemotherapy for head and neck cancer;
Documented difficulty swallowing in patients without obvious
CNS disorder;
Generalized debilitation with difficulty swallowing;
Clinical history of aspiration or history of aspiration
pneumonia; and
Head or neck injury.
Instrumental assessment of
swallowing may be needed for clinical decisions whether to place
feeding gastrostomy tubes, in the dietary management of the impaired
patient, and to plan and evaluate appropriate therapy
programs.
Instrumental assessments used for diagnostic
purposes, (e.g., fiberoptic endoscopic examination), should be
performed and interpreted by speech language pathologists or
occupational therapists under the general supervision of an
otolaryngologist or other physician with training in these
procedures or may be performed by an otolaryngologist or other
physician with appropriate training. The functional assessment and
management of dysphagia falls within the scope of practice of the
speech language pathologist or other qualified dysphagia therapist,
thus such practitioners may render a functional diagnosis of
dysphagia where allowed by state or local law. Only physicians are
qualified and licensed to render a medical diagnosis that identifies
the pathology affecting swallowing. Care should be exercised to
perform instrumental examinations in settings that assure patient
safety.
Instrumental evaluation of swallowing is used for
visualization, identification, and verification of:
the location and nature of the swallowing impairment along the
upper aerodigestive tract;
movement patterns of structures in the oral cavity and
pharynx;
timing and duration of the oral and pharyngeal stages of
swallowing.
presence or absence of aspiration;
timing and approximate percentage of aspiration; and
effective treatment methods and strategies to improve swallow
safety and efficiency;
Instrumental diagnostic procedures,
and the behavioral or dietary interventions attempted during the
examination, are used to assess their effects on reducing aspiration
and improving bolus clearance. The final interpretation of an
instrumental assessment should include a definitive diagnosis,
identification of the swallowing phase affected, and a recommended
treatment plan. The treatment plan should address appropriate
therapeutic interventions such as compensatory swallowing techniques
and postures, dietary recommendations including food and fluid
texture modification, the safety of continued oral feedings, and
recommendations for further investigations, if needed. The treating
physician ultimately determines the diagnosis and need for further
investigation.
An instrumental assessment is not medically
necessary if findings from the clinical evaluation fail to support a
suspicion of dysphagia; or, when findings from the clinical
evaluation suggest dysphagia but include one or more of the
following:
the patient is unable to cooperate or participate in an
instrumental evaluation; or
the patient’s safety is at risk,
Example: The patient is unable to initiate a swallow
response. In this case a patient would be at risk for
aspiration, if given food or liquids during a swallowing study.
However, the FEES or FEESST can yield adequate information about
swallowing physiology without feeding the patient;
in the physician's or qualifed dysphagia therapist's judgment,
the instrumental exam would not change the clinical management of
the patient; and
the patient is too medically unstable to tolerate a
procedure.
Absence of instrumental evaluation does not
preclude the patient from receiving dysphagia treatment if that
dysfunction has been reasonably identified by clinical
means.
Motion Fluoroscopic Evaluation of Swallowing
Function by Cine or Video Recording (CPT Code
92611)
Videofluoroscopic swallowing study, also known
as the modified barium swallow (MBS), is a videofluoroscopic
radiographic test that differs from the traditional barium swallow
procedures (e.g., pharyngoesophagram and upper gastrointestinal
series) in both procedure and purpose. During the MBS, the patient
is seated in an upright or semi-reclined position and given various
quantities and textures of food and/or liquids mixed with a contrast
material.
The MBS demonstrates containment of food and
liquid in the oral cavity, mastication, tongue mobility during oral
bolus transport, elevation and retraction of the velum, tongue base
retraction, upward and forward movement of the hyoid bone and
larynx, laryngeal closure, pharyngeal contraction, and extent and
duration of pharyngoesophageal segment opening. The presence,
timing, and cause of penetration or aspiration into the upper
airways are also observed. Observations of esophageal clearance,
sensation, and muscle strength may be measured directly or inferred.
Professional guidelines recommend that the service be provided in a
team setting with a physician/NPP that provides supervision of the
radiological examination and determination of the medical
diagnosis.
The performance of a videofluoroscopic assessment
is only medically necessary when the disorder cannot be
substantiated through clinical examination. It is indicated to
identify a pharyngeal deficit, aspiration is actually occurring, or
the patient is at high risk for aspiration. A videoflouroscopy is
also indicated when the clinician requires additional information to
determine appropriate treatment strategies and diet
textures.
Flexible Fiberoptic Endoscopic Evaluation of
Swallowing by Cine or Video Recording (CPT Code 92612. If cine or
video recording is not used, CPT Code
92700)
Endoscopic assessment of swallowing functions,
also known as Fiberoptic Endoscopic Evaluation of Swallowing (FEES),
involves placement of a flexible endoscope transnasally into the
hypopharynx. The procedure permits direct visualization of anatomy
as well as an assessment of amplitude, speed, briskness, and
symmetry of movement of the velopharyngeal sphincter, base of
tongue, pharynx, and larynx. Sensation is assessed by noting the
reaction of the patient to the presence of the endoscope. Findings
include briskness of swallow initiation, timing of bolus flow and
swallow initiation, adequacy of bolus driving and clearing forces,
adequacy of velar and laryngeal valving forces, penetration or
aspiration before or after the swallow, and presence of
hypopharyngeal reflux.
The patient may be evaluated at the
bedside location. FEES may be performed by a physician,
speech-language pathologist, or qualified occupational therapist.
Flexible Fiberoptic Endoscopic Evaluation, Laryngeal
Sensory Testing by Cine or Video Recording (CPT Code 92614. If cine
or video recording is not used, CPT Code 92700)
A
flexible fiberoptic laryngoscope is used in laryngeal sensory
evaluation. The sensory evaluation delivers pulses of air at
sequential pressures to elicit and document the laryngeal adductor
reflex and sensory threshold.
Flexible Fiberoptic
Endoscopic Evaluation of Swallowing and Laryngeal Sensory Testing by
Cine or Video Recording (CPT Code 92616. If cine or video recording
is not used, CPT Code 92700)
Fiberoptic Endoscopic
Evaluation of Swallowing with Sensory Testing (FEESST) is a
modification of FEES, with the addition of specialized equipment
that quantifies the sensory threshold in the larynx. FEESST may be
performed by a physician, speech-language pathologist, or qualified
occupational therapist. This may be a collaborative evaluation
involving both disciplines.
The special equipment for FEESST
includes a sensory stimulator that allows quantification of stimuli,
a television monitor, a video printer, and a video storage device.
As with the FEES procedure, velopharyngeal closure, anatomy of the
base of the tongue and hypopharynx, abduction and adduction of the
vocal folds, status of pharyngeal musculature and the patient’s
ability to handle his/her own secretions are assessed.
The
sensory evaluation is completed by delivering pulses of air at
sequential pressures to elicit and measure the laryngeal adductor
reflex. As with the FEES procedure, motor evaluation is completed by
giving various food items with different consistencies while factors
such as oral transit time, inhibition of swallowing, laryngeal
elevation, spillage, residue, condition of swallow, laryngeal
closure, reflux, aspiration, and ability to clear residue are
monitored. The entire procedure may be done at bedside. The use of
anesthesia may interfere with the sensory test and is usually not
indicated.
DYSPHAGIA TREATMENT
Medical
evaluation including the appropriate use of the swallowing
evaluation techniques listed above should result in an understanding
of the disordered swallowing mechanics and their etiology. From this
a treatment plan should be developed that may include a variety of
treatment modalities. Note that CMS Publication 100-03, Medicare
National Coverage Decisions Manual, Chapter 1, Section 170.3
requires that patients appropriate for dysphagia therapy be
motivated, moderately alert, and have some degree of deglutition
and swallowing functions.
Dysphagia services are covered
provided the services can only be safely and effectively performed
by a qualified therapist licensed, certified, or otherwise
authorized by the state in which they practice. Services normally
considered to be a routine part of nursing care are not covered as
skilled dysphagia services.
The goal for a patient is to
return to the highest level of function realistically attainable
within the context of the disability. The skills of a therapist may
not necessarily be required to attain this goal, but may be required
initially to ensure safety, select proper modalities for treatment,
then transferring the patient to a self management or caregiver
assisted treatment program.
In order for the plan of care to
be covered, it must address a condition for which dysphagia services
are an accepted method of treatment. There must be an expectation
that the condition will improve significantly in a reasonable and
generally predictable period of time based on the assessment of the
patient's rehabilitation potential.
Dysphagia services are
not covered when the functional disability or medical condition do
not require the skills of a qualified therapist.
Dysphagia
services are not covered when the documentation indicates that a
patient has attained the therapy goals or has reached the point
where no further significant practical improvement can be expected;
or when the services no longer require the skills of a therapist and
could be transitioned to a self management or caregiver assisted
program, such as when repetitive cues are required.
The
development of a maintenance regimen or home swallowing program to
delay or minimize muscular and functional deterioration may be
considered reasonable and necessary. Limited services (2-4 visits)
may be covered to establish and train the patient and/or caregiver
in a maintenance program. The skills of a therapist are not
necessary to carry out the maintenance program under ordinary
circumstances. The patient may perform such a program independently
or with the assistance of unskilled personnel or family members.
When patients with chronic, progressive conditions experience an
exacerbation or deterioration in condition, rehabilitative therapy
may be appropriate and reasonable to assist the patient to regain
lost function.
Dysphagia services visits would not be
routinely covered on a daily basis through discharge. Normally,
visit frequency would decrease as the patient's condition improves.
It may not be reasonable and necessary to extend the time of
dysphagia treatment visits for a patient, if the purpose of the
extended visits is to:
remind the patient to ask for assistance;
offer supervision of activities to monitor safety awareness;
remind a patient to slow down;
offer routine verbal cues for compensatory or adaptive
techniques already taught;
train multiple caregivers; or
begin a maintenance program after development and training is
accomplished.
In these instances, the care should be
turned over to supportive personnel or caregivers since repetitive
cues and reminders do not require the skills of a
therapist.
Treatment of Swallowing Dysfunction and/or
Oral Function for Feeding (CPT Code 92526)
Dysphagia
treatment commonly addresses the following issues:
patient caregiver training in feeding and swallowing
techniques;
proper head and body positioning;
amount of intake per swallow;
appropriate diet;
means of facilitating the swallow;
feeding techniques and need for self help eating/feeding
devices;
food consistencies (texture and size);
facilitation of more normal tone or oral facilitation
techniques;
oromotor and neuromuscular facilitation exercises to improve
oromotor control;
laryngeal elevation training;
training in laryngeal and vocal cord adduction exercises;
compensatory swallowing techniques; and
oral sensitivity training.
Patients with chronic
progressive disorders, such as Parkinson's disease, Huntington's
disease, Wilson's disease, multiple sclerosis, or Alzheimer's
disease and related dementias, do not typically show improvement in
swallowing function, but will often be helped through short-term
assistance/instruction in positioning, diet, feeding modifications,
and in the use of self-help devices. The medical record should
support short-term assistance/teaching and the establishment of a
safe and effective maintenance dysphagia program.
Chronic
diseases such as cerebral palsy, or previous head trauma or stroke,
may require monitoring of swallowing function with short-term
intervention for safety and/or swallowing effectiveness.
Documentation should support loss of function and potential for
change.
The presence of a nasogastric or gastrostomy tube
does not preclude need for treatment. Removal of a nasogastric or
gastrostomy tube may be an appropriate treatment goal.
CPT
code 92526 is a comprehensive code that includes most aspects of
dysphagia treatment. Do not use additional CPT codes in combination
with 92526 when the focus of the treatment is for swallowing. CPT code 97150 should be reported for group dysphagia
treatment. Contractors pay for outpatient physical therapy
services (which includes outpatient speech-language pathology
services) and outpatient occupational therapy services provided
simultaneously to two or more individuals by a practitioner as group
therapy services (97150). The individuals can be, but need not be
performing the same activity. The physician or therapist involved in
group therapy services must be in constant attendance, but
one-on-one patient contact is not required. (See CMS Publication
100-02, Medicare Benefit Policy Manual, Chapter 15, Section
230) CPT code 92526 is an untimed code, billed as 1 unit per
day. If two or more shorter sessions are performed during the same
day, these should be combined and billed as 1 unit.
Other
Comments:
For claims submitted to the fiscal intermediary
or Part A MAC: this coverage determination also applies within
states outside the primary geographic jurisdiction with facilities
that have nominated National Government Services to process their
claims.
Bill type codes only apply to providers who bill
these services to the fiscal intermediary or Part A MAC. Bill type
codes do not apply to physicians, other professionals and suppliers
who bill these services to the carrier or Part B MAC.
Limitation of liability and refund requirements apply when
denials are likely, whether based on medical necessity or other
coverage reasons. The provider/supplier must notify the beneficiary
in writing, prior to rendering the service, if the provider/supplier
is aware that the test, item or procedure may not be covered by
Medicare. The limitation of liability and refund requirements do not
apply when the test, item or procedure is statutorily excluded, has
no Medicare benefit category or is rendered for screening purposes.
Speech language pathology therapy services are covered
CORF services if physical therapy services are the predominate
rehabilitation services provided in the CORF. (See CMS
Publication 100-02, Medicare Benefit Policy Manual, Chapter
12, Section 40.4) To determine whether SLP therapy services are
being given in conjunction with core CORF services, see CMS
Publication 100-02, Medicare Benefit Policy Manual, Chapter
12, Section 20.1 for a description of required CORF
services.
For outpatient settings other than CORFs,
references to "physicians" throughout this policy include
non-physicians, such as nurse practitioners, clinical nurse
specialists and physician assistants. Such non-physician
practitioners, with certain exceptions, may certify, order and
establish the plan of care as authorized by State law. (See Sections
1861[s][2] and 1862[a][14] of Title XVIII of the Social Security
Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR
18543, April 7, 2000.)
Therapy
Cap
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, with a separate allowed amount for
occupational therapy. For more information on the therapy cap, see
CMS Publication 100-04, Medicare Claims Processing Manual,
Chapter 5, Section 10.2.
Swallow evaluations (CPT codes
92610, 92611, 92612, 92614, 92616, and 92700) may be performed by
physicians, speech pathologists or occupational therapists but
speech-language pathologists may not enroll and submit claims
directly to Medicare. The services of speech-language pathologists
may be billed by providers such as rehabilitation agencies, HHAs,
CORFs, hospices, outpatient departments of hospitals, physicians,
qualified NPPs, and physical therapists and occupational therapists
in private practice under the "incident to" provision.
For
services provided under the "incident to" provision, direct
supervision does not mean that the physician must be physically
present in the same room with the qualified personnel. However, the
physician must be present in the office suite and immediately
available to provide assistance and direction throughout the time
the qualified personnel is performing services. Availability of the
physician by telephone does not constitute direct
supervision.
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.
For CPT codes
92613, 92615 and 92617 to be considered for payment, a physician
must review and interpret the fiberoptic endoscopic
evaluation.
Swallowing evaluations for patients with
decreased oral intake, refusing oral intake, malnutrition, failure
to thrive, or recent weight loss, may not require the unique skills
of a therapist (and therefore would be noncovered) unless
documentation clearly supports that these conditions are suspected
to be directly related to a swallowing disorder. In these instances
applicable observations and assessments from physicians and nursing
staff should be included in any documentation sent for review to
support the need for a skilled therapy dysphagia
evaluation.
Examinations of the larynx and the pharynx done
during gastroesophagoscopy are not considered to be part of a
swallow evaluation, and are not separately payable.
CMS
Publication 100-02, Medicare Benefit Policy Manual, Chapter
15, Section 80.4.4 excludes coverage of portable x-ray services not
under the direct supervision of a physician/NPP for procedures
involving fluoroscopy, procedures involving the use of contrast
media, and procedures requiring the administration of a substance to
the patient or injection of a substance into the patient and/or
special manipulation of the patient.
Electrical stimulation
for the treatment of dysphagia (e.g., VitalStim) is not covered.
(See CMS Publication 100-03, Medicare National Coverage
Determinations Manual, Chapter 1, Section 160.2) However, if
electrical stimulation is used in addition to the reasonable and
necessary standard of care dysphagia treatment (CPT code 92526), the
use of the electronic stimulation will not cause denial of the
otherwise reasonable and necessary care.
Efficacy for deep
pharyngeal neuromuscular stimulation (DPNS) treatment of dysphagia
has not been clearly demonstrated as reasonable and necessary. DPNS
for the treatment of dysphagia is not covered. However, if DPNS is
used in addition to the reasonable and necessary standard of care
dysphagia treatment (CPT code 92526), its use will not cause denial
of the otherwise reasonable and necessary care.
Dysphagia
services rendered by a speech-language pathologist or other
qualified therapist are not reimbursed separately in a skilled
nursing facility under a qualified Part A stay under prospective
payment.
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 policy does not apply to that
Bill Type. Complete absence of all Bill Types indicates that
coverage is not influenced by Bill Type and the policy 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)
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
policy 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 policy 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
or 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 Support
Medical Necessity
It is the responsibility of the
provider to code to the highest level specified in the
ICD-9-CM (e.g., to the fourth or fifth digit). The
correct use of an ICD-9-CM code listed below does not assure
coverage of a service. The service must be reasonable and
necessary in the specific case and must meet the criteria
specified in this determination.
438.82
DYSPHAGIA CEREBROVASCULAR DISEASE
464.01
ACUTE LARYNGITIS WITH OBSTRUCTION
464.51
SUPRAGLOTTITIS UNSPECIFIED WITH
OBSTRUCTION
478.30
UNSPECIFIED PARALYSIS OF VOCAL
CORDS
478.31
PARTIAL UNILATERAL PARALYSIS OF VOCAL
CORDS
478.32
COMPLETE UNILATERAL PARALYSIS OF VOCAL
CORDS
478.33
PARTIAL BILATERAL PARALYSIS OF VOCAL
CORDS
478.34
COMPLETE BILATERAL PARALYSIS OF VOCAL
CORDS
478.6
EDEMA OF LARYNX
507.0
PNEUMONITIS DUE TO INHALATION OF FOOD OR
VOMITUS
787.20
DYSPHAGIA, UNSPECIFIED
787.21
DYSPHAGIA, ORAL PHASE
787.22
DYSPHAGIA, OROPHARYNGEAL PHASE
787.23
DYSPHAGIA, PHARYNGEAL PHASE
787.24
DYSPHAGIA, PHARYNGOESOPHAGEAL PHASE
787.29
OTHER
DYSPHAGIA
Diagnoses that Support
Medical Necessity
Not applicable
ICD-9 Codes that DO NOT
Support Medical Necessity
Not
applicable
ICD-9 Codes that DO NOT
Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT
Support Medical Necessity
Not
applicable
General Information
Documentation
Requirements
The patient's medical record must contain
documentation that fully supports the medical necessity for services
included within this LCD. (See "Indications and Limitations of
Coverage.") This documentation includes, but is not limited to,
relevant medical history, physical examination, and results of
pertinent diagnostic tests or procedures.
Medical evaluation
by the physician must establish a preliminary diagnosis and form the
basis for estimates of potential for rehabilitation prior to the
start of therapy. This evaluation may be performed in collaboration
with a speech language pathologist, qualified occupational
therapist, or radiologist. The medical evaluation must document
whether the difficulty involves the oral, pharyngeal, or esophageal
phase of swallowing.
Therapy services shall be payable when
the medical record and the information on the claim consistently and
accurately report covered therapy services. Documentation must be
legible, relevant and sufficient to justify the medical necessity of
the services billed.
The medical record information
submitted should:
paint a picture of the patient's impairments and functional
limitations requiring skilled intervention;
describe the prior functional level to assist in establishing
the patient's rehabilitative potential and prognosis;
include the results of each diagnostic test performed;
describe the skilled nature of the therapy treatment provided,
including the identification of each skilled intervention or
modality provided; and
justify that the type, frequency and duration of therapy is
medically necessary for the individual patient's
condition.
Initial
Evaluations
Dysphagia evaluations should include:
relevant history, including the change in condition that lead
to the evaluation and date of onset or exacerbation;
prior level of swallowing function and diet;
previous swallowing treatment;
current eating status, including dietary restrictions or
instructions;
level of alertness, cognition, motivation and deglutition;
presence of feeding tubes, tracheotomy tubes, paralysis;
positioning;
description of coughing and/or choking;
oral motor functioning, muscle tone, sensitivity;
description of the swallowing function and any variances from
normal; and
interpretation of the swallow examination.
For oral,
pharyngeal, or esophageal (upper one third) dysphagia, at least one
of the following conditions must be present and documented:
a history of aspiration pneumonia, reverse aspiration, chronic
aspiration, nocturnal aspiration, or aspiration pneumonia, or for
the patient at definite risk for aspiration. The following
findings are often present: nasal regurgitation, choking, frequent
coughing during swallowing, wet or gurgly voice quality after
swallowing liquid, or delayed or slow swallow reflex;
presence of oral motor disorders such as drooling, oral food
retention, and/or leakage of food or liquids placed into the
mouth;
impaired salivary gland performance and/or presence of local
structural lesions in the pharynx resulting in marked
oropharyngeal swallowing difficulties;
incoordination, sensation loss, (postural difficulties) or
other neuromotor disturbances affecting oropharyngeal abilities
necessary to close the buccal cavity and/or bite, chew, suck,
shape and squeeze the food bolus into the upper esophagus while
protecting the airway;
post-surgical reaction affecting ability to adequately use
oropharyngeal structures in swallowing;
significant weight loss directly related to non-oral
nutritional intake (g-tube feeding) and/or reaction to textures
and consistencies; or documented weight loss and/or malnutrition
of undetermined etiology that would require an evaluation to rule
out dysphagia; and
existence of other conditions such as presence of tracheostomy
tube, reduced or inadequate laryngeal elevation, labial closure,
velopharyngeal closure, laryngeal closure, or pharyngeal
peristalsis, and cricopharyngeal dysfunction.
For many
patients a clinical evaluation is adequate for substantiating the
type of dysphagia and determining appropriate interventions. If the
clinical evaluation indicates a question of pharyngeal deficit or
risk of aspiration, an instrumental assessment may be
indicated.
Each therapy discipline must have a separate plan
of care that must contain diagnosis, type, amount, frequency, and
duration of treatment, and long and short term
goals.
Certification and
Recertification
Certification, a coverage requirement
for outpatient therapy payment, requires a dated physician/NPP
signature on the therapy plan of care or some other document that
indicates approval of the plan of care. A certification differs from
an order or referral in that it must approve all required elements
of a plan of care. For additional information regarding
certification and recertification requirements, refer to CMS
Publication 100-02, Medicare Benefit Policy Manual, Chapter
15, Section 220.1.3.
Plan of Care
Plan
of care should, at a minimum, include the following elements:
the effective date for the plan of care being certified (for
initial certifications, the initial evaluation date will be
assumed to be the start date of the certified plan of care);
medical and functional diagnoses;
long term treatment goals;
type, amount, duration and frequency of therapy services;
signature, date, and professional identity of the clinician
who established the plan; and
a dated physician/NPP signature indicating that the therapy
services are or were in progress and the physician/NPP approves of
the plan. (Note: The CORF benefit does not recognize an NPP for
certification.)
Effective January 1, 2008, the interval
length between certifications shall be determined by the patient's
needs, not to exceed 90 days. Certifications which include all the
required plan of care elements will be considered valid for the
number of treatments specified in the physician-signed certification
(such as "3x/wk for 6 weeks", which will be considered as a total of
18 treatments). If treatment continues past the specified number of
visits, a recertification will be required.
Progress
Reports
Progress reports provide justification for
the medical necessity of treatment. Progress reports must be
documented at least once every 10 treatment days or every 30
calendar days, whichever is less. Writing progress notes more
frequently than the minimum is encouraged to support the medical
necessity of treatment. A progress report without a patient visit is
not a separately payable service.
Treatment
Notes
Medical record documentation is required for
every treatment day and for each therapy service. The treatment note
must include the following information:
date of treatment;
identification of the specific treatment, intervention or
activity provided;
record of the total treatment time in minutes; and
signature and credentials of each individual that provided
skilled interventions.
Skilled Level of
Care
Documentation of ongoing dysphagia treatment
should support the need for skilled services. Documentation which is
reflective of routine repetitive observation or cueing will not
support skilled therapy services
For additional information
concerning the documentation requirements for therapy services,
refer to CMS Publication 100-02, Medicare Benefit Policy
Manual, Chapter 15, Section 220.3.
Appendices
Not applicable
Utilization
Guidelines
Not applicable
Sources of Information and
Basis for Decision
This bibliography presents those sources
that were obtained during the development of this policy. National
Government Services is not responsible for the continuing viability
of Web site addresses listed below.
Bleier BS, Levine MS,
Mick R, et al. Dysphagia after chemoradiation: analysis by modified
barium swallow. Ann Otol Rhinol Laryngol.
2007;116:837-841.
Blumenfeld L, Hahn Y, Lepage A, Leonard R,
Belafsky PC. Transcutaneous electrical stimulation versus
traditional dysphagia therapy: a nonconcurrent cohort study.
Otolaryngol Head Neck Surg.
2006;135:754-757.
Carnaby-Mann GD, Crary MA. Examining the
evidence on neuromuscular electrical stimulation for swallowing: a
meta-analysis. Arch Otolaryngol Head Neck Surg.
2007;133:564-571.
Denk DM, Swoboda H, Schima W, Eibenberger
K. Prognostic factors for swallowing rehabilitation following head
and neck cancer surgery. Acta Otolaryngol.
1997;117:769-774.
Garcia-Peris P, Paron L, Velasco C, et al.
Long-term prevalence of oropharyngeal dysphagia in head and neck
cancer patients: Impact on quality of life. Clin Nutr.
2007;26:710-717.
Humbert IA, Poletto CJ, Saxon KG, et al. The
effect of surface electrical stimulation on hyolaryngeal movement in
normal individuals at rest and during swallowing. J Appl
Physiol. 2006;101:1657-1663.
Humbert IA, Poletto CJ,
Saxon KG, Kearney PR, Ludlow CL. The effect of surface electrical
stimulation on vocal fold position. Laryngoscope.
2008;118:14-19.
Ludlow CL, Humbert I, Saxon K, Poletto C,
Sonies B, Crujido L. Effects of surface electrical stimulation both
at rest and during swallowing in chronic pharyngeal Dysphagia.
Dysphagia. 2007;22:1-10.
Nguyen NP, Moltz CC, Frank C,
et al. Dysphagia following chemoradiation for locally advanced head
and neck cancer. Ann Oncol. 2004;15:383-388.
Nguyen
NP, Moltz CC, Frank C, et al. Impact of swallowing therapy on
aspiration rate following treatment for locally advanced head and
neck cancer. Oral Oncol. 2007;43:352-357.
Shaw GY,
Sechtem PR, Searl J, Keller K, Rawi TA, Dowdy E. Transcutaneous
neuromuscular electrical stimulation (VitalStim) curative therapy
for severe dysphagia: myth or reality? Ann Otol Rhinol
Laryngol. 2007;116:36-44.
Other Medicare contractor
policies consulted in development of this draft:
Empire Medicare Services carrier LCD New Jersey [L4801], New
York [L7761]
Empire Medicare Services fiscal intermediary LCD Connecticut,
Delaware New York [L686]
Indiana: 05/19/2008 Kentucky: 05/22/2008 New
York: 04/30/2008
This coverage determination does not reflect
the sole opinion of the contractor or contractor Medical Director.
Although the final decision rests with the contractor, this
determination is developed in consultation with representatives from
Advisory Committee members and/or from various state and local
provider organizations.
Start Date of Comment
Period
04/17/2008
End Date of Comment
Period
05/31/2008
Start Date of Notice
Period
12/01/2010
Revision History
Number
R3
Revision History
Explanation
R3 (effective 12/01/2010):
Based on instructions in CMS Publication 100-02, Medicare Benefit
Policy Manual, Chapter 15, Section 230, the sentence which read
“Do not use the 97xxx series of codes when billing for dysphagia
treatment.” was removed and replaced with “CPT code 97150 should be
reported for group dysphagia treatment. Contractors pay for
outpatient physical therapy services (which includes outpatient
speech-language pathology services) and outpatient occupational
therapy services provided simultaneously to two or more individuals
by a practitioner as group therapy services (97150). The individuals
can be, but need not be performing the same activity. The physician
or therapist involved in group therapy services must be in constant
attendance, but one-on-one patient contact is not
required.”
Added CPT code 97150 to the “CPT/HCPCS Codes”
section.
Minor template changes were made to reflect current
template language. No comment and notice periods required and none
given.
R2 (effective 12/01/2009): The following
reference was added to the "CMS National Coverage Policy"
section:
CMS Transmittal No. 111, Publication 100-02,
Medicare Benefit Policy Manual, Change Request #6005,
September 25, 2009, advises that speech-language pathology therapy
services are covered CORF services if physical therapy services are
the predominate rehabilitation services.
Based on the
aforementioned Change Request, the following paragraph in the
"Indications and Limitations of Coverage and/or Medical Necessity"
section was revised:
Speech language pathology therapy
services are covered CORF services if physical therapy services are
the predominate rehabilitation services provided in the CORF.
(See CMS Publication 100-02, Medicare Benefit Policy Manual,
Chapter 12, Section 40.4) To determine whether SLP therapy services
are being given in conjunction with core CORF services, see CMS
Publication 100-02, Medicare Benefit Policy Manual, Chapter
12, Section 20.1 for a description of required CORF
services.
Minor template changes were made to reflect current
template language. No comment and notice periods required and none
given.
R1 (effective 07/01/2009): Source of revision -
Internal. The following references were added to the "CMS National
Coverage Policy" section:
CMS Publication 100-04, Medicare
Claims Processing Manual, Chapter 5:Section 10 Part B Outpatient
Rehabilitation and Comprehensive Outpatient Rehabilitation Facility
(CORF) Services – General
CMS Transmittal No. 106,
Publication 100-02, Medicare Benefit Policy Manual, Change
Request #6381, April 24, 2009, advises that enrolled speech-language
pathologists may bill for services provided on or after July 1,
2009.
CMS Transmittal No. 1717, Publication 100-04,
Medicare Claims Processing Manual, Change Request #6381,
April 24, 2009, advises that enrolled speech-language pathologists
may bill for services provided on or after July 1,
2009.
Based on the aforementioned Change Request, the
following paragraphs were added under the "Therapy Cap"
section:
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. No
comment and notice periods required and none
given.
06/05/2009 - In accordance with Section 911 of the
Medicare Modernization Act of 2003, fiscal intermediary number 00270
was removed from this LCD 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 LCD as
the claims processing for Maine and Massachusetts was transitioned
to NHIC, the Part A/Part B MAC contractor in these
states.
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