Dysphagia (L2603)
Contractor Information
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Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 52280 |
Contractor Type FI |
LCD Information
Document Information
L2603 LCD Title Dysphagia Contractor's Determination Number 2000-04R1 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
Oversight Region Original Determination Effective Date For services performed on or after 12/12/2000 Original Determination Ending Date Revision Effective Date For services performed on or after 02/21/2011 Revision Ending Date |
CMS National Coverage Policy
Title XVIII of the Social Security Act, § 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Title XVIII of the Social Security Act § 1835(a)(2)(D. This section lists requirements for certification and recertification of outpatient speech pathology services.
Title XVIII of the Social Security Act § 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.
Title XVIII of the Social Security Act § 1862(a)(7). This section excludes routine physical examinations, (screening examinations).
42 CFR 410.32 indicates that diagnostic tests may only be ordered by a treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).
CMS Pub. 100-2, Medicare Benefit Policy Manual Chap. 8, § 50.3 describes physical, speech, and occupational therapy furnished by the skilled nursing facility or by others under arrangements with the facility and under its supervision.
CMS Pub. 100-2, Medicare Benefit Policy Manual Chap. 12 § 40.4 discusses coverage of issues related to SLP services provided in CORFs.
CMS Pub. 100-2, Medicare Benefit Policy Manual Chap. 15, § 80.4.4 describes coverage of portable x-ray services.
CMS Pub. 100-2 Medicare Benefit Policy Manual, Chap. 15, § 220.1 describes therapy services furnished under arrangements with providers and clinics.
CMS Pub. 100-2 Medicare Benefit Policy Manual, Chap. 15, § 230.3 outlines covered speech pathology services.
CMS Pub. 100-2 Medicare Benefit Policy Manual, Chap. 15, § 220.3.1 describes physician certification/ recertification requirements.
CMS Pub.100-3, Medicare National Coverage Determinations Manual, Chap. 1, § 170.3, describes speech-language pathology services related to dysphagia.
CMS Publication 100-04, Medicare Claims Processing Manual, Chap. 5, § 10.2 and Pub 100-20 includes documentation and billing regarding therapy caps.
Title XVIII of the Social Security Act § 1835(a)(2)(D. This section lists requirements for certification and recertification of outpatient speech pathology services.
Title XVIII of the Social Security Act § 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.
Title XVIII of the Social Security Act § 1862(a)(7). This section excludes routine physical examinations, (screening examinations).
42 CFR 410.32 indicates that diagnostic tests may only be ordered by a treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).
CMS Pub. 100-2, Medicare Benefit Policy Manual Chap. 8, § 50.3 describes physical, speech, and occupational therapy furnished by the skilled nursing facility or by others under arrangements with the facility and under its supervision.
CMS Pub. 100-2, Medicare Benefit Policy Manual Chap. 12 § 40.4 discusses coverage of issues related to SLP services provided in CORFs.
CMS Pub. 100-2, Medicare Benefit Policy Manual Chap. 15, § 80.4.4 describes coverage of portable x-ray services.
CMS Pub. 100-2 Medicare Benefit Policy Manual, Chap. 15, § 220.1 describes therapy services furnished under arrangements with providers and clinics.
CMS Pub. 100-2 Medicare Benefit Policy Manual, Chap. 15, § 230.3 outlines covered speech pathology services.
CMS Pub. 100-2 Medicare Benefit Policy Manual, Chap. 15, § 220.3.1 describes physician certification/ recertification requirements.
CMS Pub.100-3, Medicare National Coverage Determinations Manual, Chap. 1, § 170.3, describes speech-language pathology services related to dysphagia.
CMS Publication 100-04, Medicare Claims Processing Manual, Chap. 5, § 10.2 and Pub 100-20 includes documentation and billing regarding therapy caps.
Indications and Limitations of Coverage and/or Medical Necessity
Compliance with the provisions in this policy may be monitored and addressed through data analysis and medical review audits.
I. INTRODUCTION
A. CMS Regulations
Portions of the Medicare Benefit Policy Manual (CMS PUB 100) cited in this LCD are marked in italics. This LCD is not intended to replace or re-quote the entire language in the Medicare Benefit Policy Manual but to highlight portions of this Section that warrant further interpretation, guidance, and education for coverage. All CMS regulations must be followed in documenting and submitting claims.
B. This LCD is specific to dysphagia (swallowing) services rendered by Speech-Language Pathologist (SLP). Mutual of Omaha has a separate LCD regarding (SLP) services. Please see the LCD on SLP for more specific requirements regarding documentation of reasonable and necessary SLP services.
II. INDICATIONS
Dysphagia is a swallowing disorder that may be due to various neurological, structural, and cognitive deficits. Dysphagia may be the result of head trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, or encephalopathies. 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 degree of deglutition and swallowing functions are appropriate candidates for dysphagia therapy. Elements of the therapy program can include tactile thermal stimulation to heighten the sensitivity of the swallowing reflex, exercises to improve oral-motor control, training in laryngeal adduction and compensatory swallowing techniques, and positioning and dietary modifications. The treatment should be designed to ensure the swallowing safety of the patient during oral feedings and maintain adequate nutrition.
III. GUIDELINES
A. Dysphagia Evaluation
1. This evaluation is a clinical (usually bedside) one that does not involve the interpretation of dynamic radiologic studies or endoscopic studies.
2. The evaluation typically includes a bedside assessment of oral-motor functioning and signs and symptoms of oral-pharyngeal dysphagia.
3. The re-evaluation is covered after treatment has been initiated only if there is a functional change in the patient's overall condition.
4. The Evaluation code is an untimed code; therefore, only 1 unit is covered when reasonable and necessary dysphagia evaluation is billed.
B. General Dysphagia Guidelines Criteria
1. Dysphagia Criteria Oral through Upper one-third of the Esophagus
a. These phases of swallowing are described below:
(i) Oral dysphagia is defined as an inability to coordinate chewing and swallowing a bolus of food placed in the mouth (Davis, 2001). 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 thin boluses spilling prematurely into the pharynx (Perlman et al., 1997).
(The term "oropharyngeal phase" has been proposed by the National Center for Health Statistics to describe problems that occur as a bolus leaves the mouth and enters the pharynx.) Please see website listed below for additional information.
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdidx_addenda08.pdf
(ii) 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.
(iii) The phase of swallowing in the upper one-third of the esophagus has been described as the pharyngoesophageal (upper one-third), referring to passage of a bolus through this portion of the esophagus. When passage of a bolus through the upper esophageal sphincter into the esophagus is impaired, the impairment has been referred to upper esophageal dyshagia, or more currently termed pharyngoesophageal dysphagia. SLPs may be involved in screening the upper third of the esophagus for esophageal motility and gastroesophageal reflux and provide counseling and exercises.
b. Documentation must indicate the patient's level of alertness, motivation, cognition, and deglutition. In addition, at least one of the following conditions must be present:
(i) history of aspiration problems, aspiration pneumonia, or definite risk for aspiration, including risk for reverse aspiration, chronic aspiration, nocturnal aspiration, or aspiration pneumonia; these findings are often noted: nasal regurgitation, choking, frequent coughing during swallowing, wet or gurgly voice quality after swallowing liquids, or delayed or slow swallow reflex;
(ii) presence of oral motor disorders such as drooling, oral food retention, and/or leakage of food or liquids placed into the mouth;
(iii) impaired salivary gland performance and/or presence of local structural lesions in the pharynx resulting in marked oropharyngeal swallowing difficulties;
(iv) 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;
(v) post-surgical reaction affecting ability to adequately use oropharyngeal structures used in swallowing;
(vi) documented weight loss and/or malnutrition of undetermined etiology that would require an evaluation to rule out dysphagia; or
(vii) 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.
2. Dysphagia Criteria Lower two-thirds of the Esophagus
a. Esophageal dysphagia (lower two thirds of the esophagus) is 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 if they lie down too soon after meals. Esophageal dysphagia is primarily addressed through medical assessment and management.
b. 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.
3. Chronic Progressive Diseases
a. Patients with progressive disorders, such as Parkinson's disease, Huntington's disease, Wilson's disease, multiple sclerosis, or Alzheimer's disease and related dementias, may be able to retain optimal swallowing function and delay the need for tube feeding for as long as possible through short-term assistance/instruction in positioning, diet, feeding modifications, and in the use of self help devices.
NOTE: Medical documentation should support short-term assistance/teaching, the establishment of a safe and effective maintenance dysphagia program, and must support reasonable and necessary services.
b. Chronic diseases such as cerebral palsy, post-head trauma or late effects CVA may require monitoring of swallowing function with short-term intervention for safety and/or swallowing effectiveness;
(i) Documentation should relate to either loss of function, or potential for change.
(ii) As with other conditions/disorders, the reasonableness and necessity of services must be documented. Documentation should include the following:
C. Documentation
1. Safety Although the documentation must indicate appropriate treatment goals to improve a patient's swallowing function, it must also indicate that the treatment is designed to ensure that it is safe for the patient to swallow during oral feedings. Improving the patient's safety and quality of life by reduction or elimination of alternative nutritional support systems and advancement of dietary level, with improved nutritional intake should be the primary emphasis and goal of treatment. The documentation must be consistent with these goals and indicate the reasonableness and need for skilled intervention.
2. Skilled Level of Care Documentation of ongoing dysphagia treatment should support the need for skilled services such as evaluation, treatment, and diet modification.
a. Documentation which is reflective of routine, repetitive observation or cueing may not qualify as skilled rehabilitation.
b. For example, repeated visits in which the caregiver appears only to be observing the patient eating a meal, reporting on the amount of food consumed, providing verbal reminders (e.g., slow down, chin tuck, alternate solids and liquids or cough) in the absence of other skilled assistance or observation suggests a non-skilled or maintenance level of care.
3. Maintenance program Development of a maintenance program may be considered reasonable and necessary if completed during the delivery of skilled services by a skilled professional. The development of a maintenance program may include the following:
a. Evaluation
b. Development of a treatment plan
c. Staff, patient, family and/or unskilled personnel training; and
d. Infrequent re-evaluations as deemed necessary.
During the last visits for rehabilitative treatment, the clinician may develop a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to prevent decline in function. The specialized skill, knowledge and judgment of a therapist would be required, and services are covered, to design or establish the plan, assure patient safety, train the patient, family members and/or unskilled personnel and make infrequent but periodic reevaluations of the plan. (Pub. 100-2, Chap. 15, § 220.2.D)
D. Qualified Speech-Language Pathologist Defined
1. A qualified speech-language pathologist for program coverage purposes meets one of the following requirements:
2. 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, and suppliers such as physicians, NPPs, physical and occupational therapists in private practice.
(Pub. 100-2, Chap. 15, § 230.3(B))
3. The speech-language pathologist performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques.
4. 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.
(Pub. 100-2, Chap. 15, § 230.3(D))
E. Indications for Instrumental Assessments
1. 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.
2. Among the important clinical syndromes where instrumental assessment of swallowing may be helpful are:
3. Instrumental assessment of swallowing data should be used in the clinical decisions whether to place feeding gastrostomy tubes, in the every day dietary management of the impaired patient, and to order/plan/evaluate appropriate therapy programs.
4. Endoscopic assessments of swallowing functions are not recommended if an esophageal lesion is suspected or in patients who have obstructed nasopharyngeal passages bilaterally.
5. Instrumental assessment of swallowing by Videofluoroscopy and Endoscopic studies is reimbursed when deemed medically necessary and performed in the following places of service:
F. Clinical Bedside Assessment (CPT code 92610)
1. Clinical bedside examination, (commonly completed by the Speech-Language Pathologist [SLP]), 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 ability to discipline his/her own behaviors. 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 qualified therapist' clinical assessment must document history, appropriate diagnosis, current eating and nutritional status, behavioral and cognitive status environmental factors including positioning and pertinent clinical observations including oral functioning (including swallowing and general articulation), and signs and symptoms indicating possible dysphagia. The assessment must also include an impression (from the SLP perspective) and recommended plan. Assessments that are significantly lacking in these components will be considered to be not medically necessary.
2. The clinical evaluation is used to determine the necessity for further medical testing or instrumental assessment. It also provides valuable information for treatment planning, particularly for oral phase disorders.
3. An order (sometimes called a referral) for therapy service, if it is documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician. However, the certification requirements are met when the physician certifies the plan of care. If the signed order includes a plan of care (see essential requirements of plan in § 220.1.2), no further certification of the plan is required. Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.
(Pub 100-2 Chap. 15, § 220.1.1)
4. A clinical assessment is considered to be screening when it is performed in the absence of signs and symptoms of a process that is adversely impacting the patient. Screening tests in the absence of signs, symptoms or complaints are denied under section 1862(a)(7) of the Social Security Act and are additionally considered to be not medically necessary.
G. Guidelines for Instrumental Assessments Used to Study Swallowing
1. Though assessment and management of dysphagia falls within the scope of practice of the SLP, physicians are considered the only professionals qualified and licensed to render a specific medical diagnosis that identifies the pathology affecting swallowing function. However, the diagnosis of dysphagia as a functional diagnosis can be rendered by an SLP.
2. Instrumental evaluation of swallowing is used for visualization, identification, and verification of:
3. The selection of instrumental examination type is based on the patient's history, clinical presentation, patient tolerance, medical stability, setting, and availability of equipment. All procedures must be safe, within the scope of practice of the named professionals, and have a high diagnostic yield.
4. Instrumental diagnostic procedures and behavioral or dietary interventions are attempted during the examination to assess their effects on reducing aspiration and improving bolus clearance. At the conclusion of the examination, the presence, severity, and pattern of dysphagia are determined, and recommendations are made regarding safety for oral feeding and further evaluations. The final analysis and interpretation of an instrumental assessment should include a definitive diagnosis, identification of the swallowing phase(s) affected, and a recommended treatment plan. The treatment plan should address appropriate therapeutic (behavioral) interventions such as compensatory swallowing techniques and/or postures, dietary recommendations including food and/or fluid texture modification and the safety of continued oral feedings, and recommendations for further investigations if needed. (It is, however, the treating physician who ultimately determines the need for further investigation.)
5. 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:
6. Absence of instrumental evaluation does not preclude the patient from receiving dysphagia treatment if that dysfunction has been unequivocally identified by clinical means.
7. An instrumental assessment is not medically necessary in the absence of a specific order from the treating physician. An order or request for "dysphagia evaluation" is presumed to mean a clinical evaluation with the results and recommendations reported back to the treating physician. Since the instrumental assessment is an invasive diagnostic procedure, it is the responsibility of the treating physician to weight the risks and benefits and select the next step in the care of the patient. The ordering physician therefore needs to have actually examined and evaluated the patient's medical condition up to 30 days prior to the instrumental procedure in order to establish the need for an instrumental dysphagia evaluation. The physician does not need to re-examine the patient after receiving the recommendations from the SLP, but a thorough examine must have occurred prior to ordering invasive diagnostic tests.
An order (sometimes called a referral) for therapy service, if it is documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician. However, the certification requirements are met when the physician certifies the plan of care. If the signed order includes a plan of care (see essential requirements of plan in §220.1.2), no further certification of the plan is required. Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.
(The CORF services benefit does not recognize an NPP for orders and certification.)
(Pub. 100-2, Chap. 15, § 220.1.1)
8. An instrumental assessment is considered to be screening when it is performed in the absence of signs and symptoms of a process that is adversely impacting the patient. Screening tests in the absence of signs, symptoms or complaints are denied under section 1862(a)(7) of the Social Security Act and are additionally considered to be not medically necessary.
9. The equipment that is used in the examination may be fixed, mobile or portable.
(Pub. 100-2, Chap. 15, § 230.3.D.4)
H. Instrumental Assessments
1. Videofluoroscopic Swallowing Studies, (CPT code 92611)
2. Endoscopic Assessment of Swallowing Functions, (CPT code 92612 if cine or video recording is used, 92700 without cine or video recording).
a. Endoscopic assessment of swallowing functions, also known as Fiberoptic Endoscopic Evaluation of Swallowing (FEES), involves placement of a flexible endoscope transnasally to 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/clearing forces, adequacy of velar and laryngeal valving forces, penetration and/or aspiration, before or after the swallow, and presence of hypopharyngeal reflux.
b. The patient may be evaluated at the bedside location. FEES may be performed by a physician or speech-language pathologist with general physician supervision and may be a collaborative evaluation involving both disciplines.
c. In skilled nursing facilities, the FEES may be performed by SLPs under the general supervision of an otolaryngologist or other physician and may be a collaboration of both disciplines. The following requirements apply to the SNF setting:
d. In a hospital setting, the physician supervision requirement is presumed to be met and need not be documented.
3. Fiberoptic Endoscopic Evaluation, laryngeal sensory testing, (CPT code 92614 if cine or video recording is used, 92700 without cine or video recording).
4. Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST), (CPT code 92616 if cine or video recording is used, 92700 without cine or video recording).
5. Other instrumental assessments may occasionally be indicated to study swallowing. The appropriateness of the assessment procedure will be based on the nature of the disorder and standard of practice.
When performing these procedures in a SNF, or nursing home, it is essential that a patient' safety is established prior to the performance of the procedure.
I. Dysphagia Treatment (CPT Code 92526)
1. Individuals of all ages are treated on the basis of the swallowing function assessment. At the conclusion of the assessment, the presence, severity, and pattern of dysphagia should be determined, and recommendations made of therapeutic interventions, dietary changes, and further evaluations. The therapist or the physician must develop an individualized care plan if therapy is to be undertaken. Courses of therapy delivered in the absence of a plan of care or without the certification of the physician will be considered to be not medically necessary as they are not coordinated with the medical needs of the patient. For outpatient settings other than CORFs, nurse practitioners, clinical nurse specialists and physician assistants may also certify, order and establish the plan of care for dysphagia services.
2. The plan of care must contain clear goals and must specifically address each problem identified in the assessment. Issues typically addressed include:
3. For therapy to be medically necessary there must be a reasonable expectation that the patient will make material improvement within a reasonable and predictable period of time. The plan of care must set definable goals and document an anticipated timeframe for completion. The establishment of a functional maintenance program by a therapist may be an acceptable goal if clinical improvement is unlikely and the underlying pathology suggests that deterioration would otherwise occur.
4. Disorders limited wholly or predominantly to the lower and middle esophagus will not be considered medically necessary although the consultative advice from the recommendations in the report of the evaluation may be beneficial. Typical recommendations would include medical management for reflux, nutritional consultation, repositioning and other compensatory techniques to improve the peristalsis of food.
5. The presence of a nasogastric, gastrostomy, or jejunostomy tube does not preclude the need for treatment as removal of a nasogastric, gastrostomy, or jejunostomy tube may be an appropriate treatment goal.
6. The duration of therapy for swallowing disorders may vary from patient to patient. With some patients all that may be necessary is the establishment of a maintenance program, which includes: instruction of the patient and caregivers, including family members. This can be performed in one to three sessions following the completion of the evaluation. Dysphagia therapy sessions are not time limited, so it is expected that each session will be limited by the ability of the patient to tolerate, comprehend, absorb and remember the instructions. In all instances the medical record must justify the need for recurring sessions.
IV. LIMITATIONS
A. The various forms of electrical stimulation for the treatment of dysphagia (e.g., Vitalstim which is a type of neuromuscular electrical stimulation therapy for the treatment of dysphagia, that uses small electrical currents to stimulate the muscles responsible for swallowing) are not covered.
1. Surface electrical stimulation
a. Surface electrical stimulation is applied to the skin, which activates sensory fibers in the skin and only those muscles immediately below the skin surface, if enough intensity is applied. Electrical stimulation over the surface of the skin will provide stimulation of the skin but has not been shown to elicit movement to control laryngeal elevation (Freed et al., 2001).
b. Based upon review of the scientific and clinical literature, the clinical efficacy and clinical utility of this service remains unproven; in fact, there is concerning evidence that this modality places some individuals at risk of aspiration. However, because the code for dysphagia treatment is a comprehensive code that includes all treatment approaches, payment may be made if other medically necessary dysphagia treatments occur during the same session that electrical stimulation is rendered.
2. Deep pharyngeal neuromuscular stimulation (DPNS)
a. Deep pharyngeal neuromuscular stimulation is a systematized therapeutic method for pharyngeal dysphagia which utilizes "direct" neuromuscular stimulation to the pharyngeal musculature to restore muscle strength, endurance, pharyngeal reflex responses and pharyngeal reflex coordination for a restored, coordinated swallow response.
b. Based upon review of the scientific and clinical literature, the clinical efficacy and clinical utility of this service remains unproven. However, because the code for dysphagia treatment is a comprehensive code that includes all treatment approaches, payment may be made for other medically necessary dysphagia treatments.
3. Instrinsic stimulation
a. By placing electrodes intramuscularly, individual muscles can be stimulated to achieve specific movements. Intramuscular stimulation of the mylo- and thyrohyoid muscles at rest can raise the larynx 50% of the distance it elevates during 2-ml water swallows (Burnett et al. 2003). If applied at the appropriate moment during swallowing, neuromuscular stimulation could potentially augment a patient' reflexively produced laryngeal elevation.
b. Based upon review of the scientific and clinical literature, the clinical efficacy and clinical utility of this service remains unproven. However, because the code for dysphagia treatment is a comprehensive code that includes all treatment approaches, payment may be made for other medically necessary dysphagia treatments.
B. 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).
C. Based upon analysis of claims data, research and evidence based practice guidelines, CMS has identified conditions and complexities that will be excepted from caps. For additional information on Medicare requirements for therapy cap exceptions see: http://www.cms.hhs.gov/Transmittals/downloads/R855CP.pdf.
For all therapy services, including those provided before and after a therapy cap exception is allowed, payment requires that documentation supports the medical necessity of the services. (Medicare Claims Processing Manual, Chapter 5 section C1).
I. INTRODUCTION
A. CMS Regulations
Portions of the Medicare Benefit Policy Manual (CMS PUB 100) cited in this LCD are marked in italics. This LCD is not intended to replace or re-quote the entire language in the Medicare Benefit Policy Manual but to highlight portions of this Section that warrant further interpretation, guidance, and education for coverage. All CMS regulations must be followed in documenting and submitting claims.
B. This LCD is specific to dysphagia (swallowing) services rendered by Speech-Language Pathologist (SLP). Mutual of Omaha has a separate LCD regarding (SLP) services. Please see the LCD on SLP for more specific requirements regarding documentation of reasonable and necessary SLP services.
II. INDICATIONS
Dysphagia is a swallowing disorder that may be due to various neurological, structural, and cognitive deficits. Dysphagia may be the result of head trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, or encephalopathies. 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 degree of deglutition and swallowing functions are appropriate candidates for dysphagia therapy. Elements of the therapy program can include tactile thermal stimulation to heighten the sensitivity of the swallowing reflex, exercises to improve oral-motor control, training in laryngeal adduction and compensatory swallowing techniques, and positioning and dietary modifications. The treatment should be designed to ensure the swallowing safety of the patient during oral feedings and maintain adequate nutrition.
III. GUIDELINES
A. Dysphagia Evaluation
1. This evaluation is a clinical (usually bedside) one that does not involve the interpretation of dynamic radiologic studies or endoscopic studies.
2. The evaluation typically includes a bedside assessment of oral-motor functioning and signs and symptoms of oral-pharyngeal dysphagia.
3. The re-evaluation is covered after treatment has been initiated only if there is a functional change in the patient's overall condition.
4. The Evaluation code is an untimed code; therefore, only 1 unit is covered when reasonable and necessary dysphagia evaluation is billed.
B. General Dysphagia Guidelines Criteria
1. Dysphagia Criteria Oral through Upper one-third of the Esophagus
a. These phases of swallowing are described below:
(i) Oral dysphagia is defined as an inability to coordinate chewing and swallowing a bolus of food placed in the mouth (Davis, 2001). 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 thin boluses spilling prematurely into the pharynx (Perlman et al., 1997).
(The term "oropharyngeal phase" has been proposed by the National Center for Health Statistics to describe problems that occur as a bolus leaves the mouth and enters the pharynx.) Please see website listed below for additional information.
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdidx_addenda08.pdf
(ii) 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.
(iii) The phase of swallowing in the upper one-third of the esophagus has been described as the pharyngoesophageal (upper one-third), referring to passage of a bolus through this portion of the esophagus. When passage of a bolus through the upper esophageal sphincter into the esophagus is impaired, the impairment has been referred to upper esophageal dyshagia, or more currently termed pharyngoesophageal dysphagia. SLPs may be involved in screening the upper third of the esophagus for esophageal motility and gastroesophageal reflux and provide counseling and exercises.
b. Documentation must indicate the patient's level of alertness, motivation, cognition, and deglutition. In addition, at least one of the following conditions must be present:
(i) history of aspiration problems, aspiration pneumonia, or definite risk for aspiration, including risk for reverse aspiration, chronic aspiration, nocturnal aspiration, or aspiration pneumonia; these findings are often noted: nasal regurgitation, choking, frequent coughing during swallowing, wet or gurgly voice quality after swallowing liquids, or delayed or slow swallow reflex;
(ii) presence of oral motor disorders such as drooling, oral food retention, and/or leakage of food or liquids placed into the mouth;
(iii) impaired salivary gland performance and/or presence of local structural lesions in the pharynx resulting in marked oropharyngeal swallowing difficulties;
(iv) 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;
(v) post-surgical reaction affecting ability to adequately use oropharyngeal structures used in swallowing;
(vi) documented weight loss and/or malnutrition of undetermined etiology that would require an evaluation to rule out dysphagia; or
(vii) 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.
2. Dysphagia Criteria Lower two-thirds of the Esophagus
a. Esophageal dysphagia (lower two thirds of the esophagus) is 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 if they lie down too soon after meals. Esophageal dysphagia is primarily addressed through medical assessment and management.
b. 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.
3. Chronic Progressive Diseases
a. Patients with progressive disorders, such as Parkinson's disease, Huntington's disease, Wilson's disease, multiple sclerosis, or Alzheimer's disease and related dementias, may be able to retain optimal swallowing function and delay the need for tube feeding for as long as possible through short-term assistance/instruction in positioning, diet, feeding modifications, and in the use of self help devices.
NOTE: Medical documentation should support short-term assistance/teaching, the establishment of a safe and effective maintenance dysphagia program, and must support reasonable and necessary services.
b. Chronic diseases such as cerebral palsy, post-head trauma or late effects CVA may require monitoring of swallowing function with short-term intervention for safety and/or swallowing effectiveness;
(i) Documentation should relate to either loss of function, or potential for change.
(ii) As with other conditions/disorders, the reasonableness and necessity of services must be documented. Documentation should include the following:
- changes in condition or functional status;
- history and outcome of previous treatment for the same condition; and
- other information which justifies the start of care.
C. Documentation
1. Safety Although the documentation must indicate appropriate treatment goals to improve a patient's swallowing function, it must also indicate that the treatment is designed to ensure that it is safe for the patient to swallow during oral feedings. Improving the patient's safety and quality of life by reduction or elimination of alternative nutritional support systems and advancement of dietary level, with improved nutritional intake should be the primary emphasis and goal of treatment. The documentation must be consistent with these goals and indicate the reasonableness and need for skilled intervention.
2. Skilled Level of Care Documentation of ongoing dysphagia treatment should support the need for skilled services such as evaluation, treatment, and diet modification.
a. Documentation which is reflective of routine, repetitive observation or cueing may not qualify as skilled rehabilitation.
b. For example, repeated visits in which the caregiver appears only to be observing the patient eating a meal, reporting on the amount of food consumed, providing verbal reminders (e.g., slow down, chin tuck, alternate solids and liquids or cough) in the absence of other skilled assistance or observation suggests a non-skilled or maintenance level of care.
3. Maintenance program Development of a maintenance program may be considered reasonable and necessary if completed during the delivery of skilled services by a skilled professional. The development of a maintenance program may include the following:
a. Evaluation
b. Development of a treatment plan
c. Staff, patient, family and/or unskilled personnel training; and
d. Infrequent re-evaluations as deemed necessary.
During the last visits for rehabilitative treatment, the clinician may develop a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to prevent decline in function. The specialized skill, knowledge and judgment of a therapist would be required, and services are covered, to design or establish the plan, assure patient safety, train the patient, family members and/or unskilled personnel and make infrequent but periodic reevaluations of the plan. (Pub. 100-2, Chap. 15, § 220.2.D)
D. Qualified Speech-Language Pathologist Defined
1. A qualified speech-language pathologist for program coverage purposes meets one of the following requirements:
- The education and experience requirements for a Certificate of Clinical Competence in (speech-language pathology) granted by the American Speech-Language Hearing Association; or
- Meets the educational requirements for certification and is in the process of accumulating the supervised experience required for certification.
2. 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, and suppliers such as physicians, NPPs, physical and occupational therapists in private practice.
(Pub. 100-2, Chap. 15, § 230.3(B))
3. The speech-language pathologist performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques.
4. 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.
(Pub. 100-2, Chap. 15, § 230.3(D))
E. Indications for Instrumental Assessments
1. 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.
2. Among the important clinical syndromes where instrumental assessment of swallowing may be helpful are:
- Patients with stroke or other central nervous system (CNS) disorder with associated impairment of speech and swallowing;
- Patients with surgical blation or radiation due to head and neck cancer with documented difficulty in swallowing;
- Patients without obvious CNS disorder, but with documented difficulty in swallowing;
- Patients with generalized debilitation and with difficulty swallowing food;
- Patients with a clinical history of aspiration or a history of
aspiration pneumonia; or - Patients with head or neck (throat) injury.
3. Instrumental assessment of swallowing data should be used in the clinical decisions whether to place feeding gastrostomy tubes, in the every day dietary management of the impaired patient, and to order/plan/evaluate appropriate therapy programs.
4. Endoscopic assessments of swallowing functions are not recommended if an esophageal lesion is suspected or in patients who have obstructed nasopharyngeal passages bilaterally.
5. Instrumental assessment of swallowing by Videofluoroscopy and Endoscopic studies is reimbursed when deemed medically necessary and performed in the following places of service:
- Office
- Inpatient hospital
- Outpatient hospital
- Hospital emergency room
- Comprehensive outpatient rehabilitation facility
- Skilled Nursing Facility or
- Nursing Home
F. Clinical Bedside Assessment (CPT code 92610)
1. Clinical bedside examination, (commonly completed by the Speech-Language Pathologist [SLP]), 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 ability to discipline his/her own behaviors. 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 qualified therapist' clinical assessment must document history, appropriate diagnosis, current eating and nutritional status, behavioral and cognitive status environmental factors including positioning and pertinent clinical observations including oral functioning (including swallowing and general articulation), and signs and symptoms indicating possible dysphagia. The assessment must also include an impression (from the SLP perspective) and recommended plan. Assessments that are significantly lacking in these components will be considered to be not medically necessary.
2. The clinical evaluation is used to determine the necessity for further medical testing or instrumental assessment. It also provides valuable information for treatment planning, particularly for oral phase disorders.
3. An order (sometimes called a referral) for therapy service, if it is documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician. However, the certification requirements are met when the physician certifies the plan of care. If the signed order includes a plan of care (see essential requirements of plan in § 220.1.2), no further certification of the plan is required. Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.
(Pub 100-2 Chap. 15, § 220.1.1)
4. A clinical assessment is considered to be screening when it is performed in the absence of signs and symptoms of a process that is adversely impacting the patient. Screening tests in the absence of signs, symptoms or complaints are denied under section 1862(a)(7) of the Social Security Act and are additionally considered to be not medically necessary.
G. Guidelines for Instrumental Assessments Used to Study Swallowing
1. Though assessment and management of dysphagia falls within the scope of practice of the SLP, physicians are considered the only professionals qualified and licensed to render a specific medical diagnosis that identifies the pathology affecting swallowing function. However, the diagnosis of dysphagia as a functional diagnosis can be rendered by an SLP.
2. Instrumental evaluation of swallowing is used for visualization, identification, and verification of:
- the location(s) and nature of the swallowing impairment along the upper aerodigestive tract;
- presence or absence of aspiration and the swallowing disorder causing it;
- timing and approximate percentage of aspiration;
- effective treatment methods and strategies to improve swallow safety and efficiency;
- movement patterns of structures in the oral cavity and pharynx; and
- timing and duration of the oral and pharyngeal stages of swallowing.
3. The selection of instrumental examination type is based on the patient's history, clinical presentation, patient tolerance, medical stability, setting, and availability of equipment. All procedures must be safe, within the scope of practice of the named professionals, and have a high diagnostic yield.
4. Instrumental diagnostic procedures and behavioral or dietary interventions are attempted during the examination to assess their effects on reducing aspiration and improving bolus clearance. At the conclusion of the examination, the presence, severity, and pattern of dysphagia are determined, and recommendations are made regarding safety for oral feeding and further evaluations. The final analysis and interpretation of an instrumental assessment should include a definitive diagnosis, identification of the swallowing phase(s) affected, and a recommended treatment plan. The treatment plan should address appropriate therapeutic (behavioral) interventions such as compensatory swallowing techniques and/or postures, dietary recommendations including food and/or fluid texture modification and the safety of continued oral feedings, and recommendations for further investigations if needed. (It is, however, the treating physician who ultimately determines the need for further investigation.)
5. 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;
- the patient' 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 speech-language pathologist' judgment, the instrumental exam would not change the clinical management of the patient; or
- the patient is too medically unstable to tolerate a procedure.
6. Absence of instrumental evaluation does not preclude the patient from receiving dysphagia treatment if that dysfunction has been unequivocally identified by clinical means.
7. An instrumental assessment is not medically necessary in the absence of a specific order from the treating physician. An order or request for "dysphagia evaluation" is presumed to mean a clinical evaluation with the results and recommendations reported back to the treating physician. Since the instrumental assessment is an invasive diagnostic procedure, it is the responsibility of the treating physician to weight the risks and benefits and select the next step in the care of the patient. The ordering physician therefore needs to have actually examined and evaluated the patient's medical condition up to 30 days prior to the instrumental procedure in order to establish the need for an instrumental dysphagia evaluation. The physician does not need to re-examine the patient after receiving the recommendations from the SLP, but a thorough examine must have occurred prior to ordering invasive diagnostic tests.
An order (sometimes called a referral) for therapy service, if it is documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician. However, the certification requirements are met when the physician certifies the plan of care. If the signed order includes a plan of care (see essential requirements of plan in §220.1.2), no further certification of the plan is required. Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.
(The CORF services benefit does not recognize an NPP for orders and certification.)
(Pub. 100-2, Chap. 15, § 220.1.1)
8. An instrumental assessment is considered to be screening when it is performed in the absence of signs and symptoms of a process that is adversely impacting the patient. Screening tests in the absence of signs, symptoms or complaints are denied under section 1862(a)(7) of the Social Security Act and are additionally considered to be not medically necessary.
9. The equipment that is used in the examination may be fixed, mobile or portable.
(Pub. 100-2, Chap. 15, § 230.3.D.4)
H. Instrumental Assessments
1. Videofluoroscopic Swallowing Studies, (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 procedure, 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.
- This procedure includes observation of containment of the food/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 observed. Observations of esophageal 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 who provides supervision of the radiological examination and interpretation of medical conditions revealed in it.
- The performance of a videofluoroscopic assessment is medically necessary when the disorder cannot be substantiated through oral examination and additional information is needed to evaluate for concerns such as; presence of a pharyngeal deficit, aspiration, high risk for aspiration or when the speech-language pathologist requires additional information to determine appropriate treatment strategies and diet textures.
2. Endoscopic Assessment of Swallowing Functions, (CPT code 92612 if cine or video recording is used, 92700 without cine or video recording).
a. Endoscopic assessment of swallowing functions, also known as Fiberoptic Endoscopic Evaluation of Swallowing (FEES), involves placement of a flexible endoscope transnasally to 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/clearing forces, adequacy of velar and laryngeal valving forces, penetration and/or aspiration, before or after the swallow, and presence of hypopharyngeal reflux.
b. The patient may be evaluated at the bedside location. FEES may be performed by a physician or speech-language pathologist with general physician supervision and may be a collaborative evaluation involving both disciplines.
c. In skilled nursing facilities, the FEES may be performed by SLPs under the general supervision of an otolaryngologist or other physician and may be a collaboration of both disciplines. The following requirements apply to the SNF setting:
- a provision for monitoring to assure that the patient' condition is stable immediately before and after the procedure is performed (e.g. vital signs);
- a registered nurse must be immediately available; and
- general physician supervision means the physician is accessible but not required on the premises.
d. In a hospital setting, the physician supervision requirement is presumed to be met and need not be documented.
3. Fiberoptic Endoscopic Evaluation, laryngeal sensory testing, (CPT code 92614 if cine or video recording is used, 92700 without cine or video recording).
- A flexible fiberoptic laryngoscope is used in laryngeal sensory evaluation. The sensory evaluation is completed by delivering pulses of air at sequential pressures to elicit the laryngeal adductor reflex. A sensory threshold is thus established.
4. Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST), (CPT code 92616 if cine or video recording is used, 92700 without cine or video recording).
5. Other instrumental assessments may occasionally be indicated to study swallowing. The appropriateness of the assessment procedure will be based on the nature of the disorder and standard of practice.
When performing these procedures in a SNF, or nursing home, it is essential that a patient' safety is established prior to the performance of the procedure.
I. Dysphagia Treatment (CPT Code 92526)
1. Individuals of all ages are treated on the basis of the swallowing function assessment. At the conclusion of the assessment, the presence, severity, and pattern of dysphagia should be determined, and recommendations made of therapeutic interventions, dietary changes, and further evaluations. The therapist or the physician must develop an individualized care plan if therapy is to be undertaken. Courses of therapy delivered in the absence of a plan of care or without the certification of the physician will be considered to be not medically necessary as they are not coordinated with the medical needs of the patient. For outpatient settings other than CORFs, nurse practitioners, clinical nurse specialists and physician assistants may also certify, order and establish the plan of care for dysphagia services.
2. The plan of care must contain clear goals and must specifically address each problem identified in the assessment. Issues typically addressed include:
- Patient and care-giver training in feeding and swallowing techniques;
- Proper head and body positioning;
- Amount of intake per swallow;
- Appropriate and safest diet;
- Means of facilitating the swallow;
- Feeding techniques and need for self help eating/feeding devices;
- Food and fluid consistencies (texture and size);
- Facilitation of more normal tone or oral facilitation techniques ;
- Oromotor and/or neuromuscular facilitation exercises to improve oromotor control;
- Training in laryngeal and vocal cord adduction exercises;
- Techniques to reduce shortness of breath or fatigue during duration of meal; and
- Oral sensitivity training.
3. For therapy to be medically necessary there must be a reasonable expectation that the patient will make material improvement within a reasonable and predictable period of time. The plan of care must set definable goals and document an anticipated timeframe for completion. The establishment of a functional maintenance program by a therapist may be an acceptable goal if clinical improvement is unlikely and the underlying pathology suggests that deterioration would otherwise occur.
4. Disorders limited wholly or predominantly to the lower and middle esophagus will not be considered medically necessary although the consultative advice from the recommendations in the report of the evaluation may be beneficial. Typical recommendations would include medical management for reflux, nutritional consultation, repositioning and other compensatory techniques to improve the peristalsis of food.
5. The presence of a nasogastric, gastrostomy, or jejunostomy tube does not preclude the need for treatment as removal of a nasogastric, gastrostomy, or jejunostomy tube may be an appropriate treatment goal.
6. The duration of therapy for swallowing disorders may vary from patient to patient. With some patients all that may be necessary is the establishment of a maintenance program, which includes: instruction of the patient and caregivers, including family members. This can be performed in one to three sessions following the completion of the evaluation. Dysphagia therapy sessions are not time limited, so it is expected that each session will be limited by the ability of the patient to tolerate, comprehend, absorb and remember the instructions. In all instances the medical record must justify the need for recurring sessions.
IV. LIMITATIONS
A. The various forms of electrical stimulation for the treatment of dysphagia (e.g., Vitalstim which is a type of neuromuscular electrical stimulation therapy for the treatment of dysphagia, that uses small electrical currents to stimulate the muscles responsible for swallowing) are not covered.
1. Surface electrical stimulation
a. Surface electrical stimulation is applied to the skin, which activates sensory fibers in the skin and only those muscles immediately below the skin surface, if enough intensity is applied. Electrical stimulation over the surface of the skin will provide stimulation of the skin but has not been shown to elicit movement to control laryngeal elevation (Freed et al., 2001).
b. Based upon review of the scientific and clinical literature, the clinical efficacy and clinical utility of this service remains unproven; in fact, there is concerning evidence that this modality places some individuals at risk of aspiration. However, because the code for dysphagia treatment is a comprehensive code that includes all treatment approaches, payment may be made if other medically necessary dysphagia treatments occur during the same session that electrical stimulation is rendered.
2. Deep pharyngeal neuromuscular stimulation (DPNS)
a. Deep pharyngeal neuromuscular stimulation is a systematized therapeutic method for pharyngeal dysphagia which utilizes "direct" neuromuscular stimulation to the pharyngeal musculature to restore muscle strength, endurance, pharyngeal reflex responses and pharyngeal reflex coordination for a restored, coordinated swallow response.
b. Based upon review of the scientific and clinical literature, the clinical efficacy and clinical utility of this service remains unproven. However, because the code for dysphagia treatment is a comprehensive code that includes all treatment approaches, payment may be made for other medically necessary dysphagia treatments.
3. Instrinsic stimulation
a. By placing electrodes intramuscularly, individual muscles can be stimulated to achieve specific movements. Intramuscular stimulation of the mylo- and thyrohyoid muscles at rest can raise the larynx 50% of the distance it elevates during 2-ml water swallows (Burnett et al. 2003). If applied at the appropriate moment during swallowing, neuromuscular stimulation could potentially augment a patient' reflexively produced laryngeal elevation.
b. Based upon review of the scientific and clinical literature, the clinical efficacy and clinical utility of this service remains unproven. However, because the code for dysphagia treatment is a comprehensive code that includes all treatment approaches, payment may be made for other medically necessary dysphagia treatments.
B. 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).
C. Based upon analysis of claims data, research and evidence based practice guidelines, CMS has identified conditions and complexities that will be excepted from caps. For additional information on Medicare requirements for therapy cap exceptions see: http://www.cms.hhs.gov/Transmittals/downloads/R855CP.pdf.
For all therapy services, including those provided before and after a therapy cap exception is allowed, payment requires that documentation supports the medical necessity of the services. (Medicare Claims Processing Manual, Chapter 5 section C1).
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.
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 014x | Hospital - Laboratory Services Provided to Non-patients |
| 021x | Skilled Nursing - Inpatient (Including Medicare Part A) |
| 022x | Skilled Nursing - Inpatient (Medicare Part B only) |
| 023x | Skilled Nursing - Outpatient |
| 074x | Clinic - Outpatient Rehabilitation Facility (ORF) |
| 075x | Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) |
| 085x | Critical Access Hospital |
Revenue Codes:
CPT/HCPCS 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 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.
| 320X | Radiology - Diagnostic - General Classification |
| 0440 | Speech Therapy - Language Pathology - General Classification |
| 0444 | Speech Therapy - Language Pathology - Evaluation or Reevaluation |
| 0750 | Gastro-Intestinal (GI) Services - General Classification |
Listing of HCPCS codes contained in this instruction does not
assure coverage of the specific service. Current coverage criteria
still apply.
assure coverage of the specific service. Current coverage criteria
still apply.
| 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; |
| 92614 | FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION, LARYNGEAL SENSORY TESTING BY CINE OR VIDEO RECORDING; |
| 92616 | FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING AND LARYNGEAL SENSORY TESTING BY CINE OR VIDEO RECORDING; |
| 92700 | UNLISTED OTORHINOLARYNGOLOGICAL SERVICE OR PROCEDURE |
ICD-9 Codes that Support Medical Necessity
Please note that this is not an all inclusive list (documentation
must clearly support the need for the services) Note: It is the providers responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. It is not enough to link the procedure to a correct, payable ICD-9-CM diagnosis code. The diagnosis or clinical suspicion must be present for the procedure to be paid.
must clearly support the need for the services) Note: It is the providers responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. It is not enough to link the procedure to a correct, payable ICD-9-CM diagnosis code. The diagnosis or clinical suspicion must be present for the procedure to be paid.
| 342.00 - 342.92 | FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE |
| 434.00 - 434.91 | CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION - CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION |
| 438.82 | DYSPHAGIA CEREBROVASCULAR DISEASE |
| 478.30 - 478.34 | UNSPECIFIED PARALYSIS OF VOCAL CORDS - COMPLETE BILATERAL PARALYSIS OF VOCAL CORDS |
| 507.0 | PNEUMONITIS DUE TO INHALATION OF FOOD OR VOMITUS |
| 530.0 | ACHALASIA AND CARDIOSPASM |
| 530.3 | STRICTURE AND STENOSIS OF ESOPHAGUS |
| 530.6 | DIVERTICULUM OF ESOPHAGUS ACQUIRED |
| 530.81 | ESOPHAGEAL REFLUX |
| 783.3 | FEEDING DIFFICULTIES AND MISMANAGEMENT |
| 784.2 | SWELLING MASS OR LUMP IN HEAD AND NECK |
| 786.2 | COUGH |
| 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 |
| 793.1 | NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF LUNG FIELD |
| 933.1 | FOREIGN BODY IN LARYNX |
| 934.0 | FOREIGN BODY IN TRACHEA |
| 934.1 | FOREIGN BODY IN MAIN BRONCHUS |
| V41.6 | PROBLEMS WITH SWALLOWING AND MASTICATION |
| V48.3 | MECHANICAL AND MOTOR PROBLEMS WITH NECK AND TRUNK |
Diagnoses that Support Medical Necessity
See “ICD-9 Codes That Support Medical Necessity" Section
ICD-9 Codes that DO NOT Support Medical Necessity
Any ICD-9 Code not listed in the “ICD-9 Codes That Support Medical Necessity" Section
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
General Information
I. Following is a list of the information that should be maintained and made available to Medicare upon request:
A. Documentation for a diagnosis of dysphagia shall include:
B. Documentation supporting the services as medically indicated needs to be legible and maintained in the patient's medical record.
II. Professional Assessment Documentation
A. Medical history
B. Current eating status:
C. Clinical observations such as:
D. This information is used to determine necessity for further medical testing, e.g., videofluoroscopy, upper GI series, endoscopy. If videofluoroscopic assessment is conducted (modified barium swallow), documentation must establish that the exact diagnosis of the swallowing disorder cannot be substantiated through oral exam and there is a question as to whether aspiration is occurring. The assessment and final analysis and interpretation should include a definitive diagnosis, identification of the swallowing phase(s) affected, and a recommended treatment plan.
NOTE: The videofluoroscopic (radiographic) examination is useful in evaluating all aspects of the oral and pharyngeal stages of the swallow. The bedside evaluation provides reliable information about the oral cavity and oral function only. The bedside assessment does not allow for a definitive determination of the etiology of, or the presence of, any aspiration. A patient may aspirate without coughing or giving any other external sign that food has entered the airway. Aspiration is a symptom of a swallowing disorder. This necessitates an assessment of the exact nature of the anatomic or physiologic swallowing problem, which results in the aspiration.
As with all rehabilitation services, there must be a reasonable expectation that the patient will make material improvement within a reasonable period of time.
Professional Services Services are sometimes performed by SLPs, occupational therapists, and physical therapists, in concert with other health professionals. Services are often performed as a team with each member performing unique roles, which do not duplicate services of others. Services may include, but are not limited to, the following example:
EXAMPLE: One professional assisting with positioning, adaptive self help devices, inhibiting abnormal oromotor and/or postural reflexes while another professional is addressing specific exercises to improve oromotor control, determining appropriate food consistency form, and assisting the patient in difficulty with muscular movements necessary to close the buccal cavity or shape food in the mouth in preparation for swallowing. Another professional might be addressing a different role, such as increasing muscle strength, sitting balance, and head control.
Services of Speech-Language Pathology Support Personnel
Services of Speech-Language Pathology assistants are not recognized for Medicare coverage. Services provided by Speech-Language Pathology assistants, even if they are licensed to provide services in their states, will be considered unskilled services and denied as not reasonable and necessary if they are billed as therapy services.
Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.
Appendices
A. Documentation for a diagnosis of dysphagia shall include:
- the presence of a swallowing dysfunction;
- the severity of its impact on the patient;
- any noticeable pattern(s) demonstrated;
- a formal descriptive narrative of the services provided;
- the primary diagnosis and the resulting secondary condition;
- details of the examination supporting the medical indications; and
- An order (sometimes called a referral) for therapy service, if it is documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician.
(Pub 100-2 Chapter 15, §220.1.1)
B. Documentation supporting the services as medically indicated needs to be legible and maintained in the patient's medical record.
II. Professional Assessment Documentation
A. Medical history
B. Current eating status:
- including dietary restrictions or instructions.
C. Clinical observations such as:
- presence of a feeding tube;
- paralysis;
- coughing or choking;
- oral motor structure and function;
- oral sensitivity;
- muscle tone;
- cognition;
- positioning;
- laryngeal function;
- oropharyngeal reflexes; and
- swallowing function.
D. This information is used to determine necessity for further medical testing, e.g., videofluoroscopy, upper GI series, endoscopy. If videofluoroscopic assessment is conducted (modified barium swallow), documentation must establish that the exact diagnosis of the swallowing disorder cannot be substantiated through oral exam and there is a question as to whether aspiration is occurring. The assessment and final analysis and interpretation should include a definitive diagnosis, identification of the swallowing phase(s) affected, and a recommended treatment plan.
NOTE: The videofluoroscopic (radiographic) examination is useful in evaluating all aspects of the oral and pharyngeal stages of the swallow. The bedside evaluation provides reliable information about the oral cavity and oral function only. The bedside assessment does not allow for a definitive determination of the etiology of, or the presence of, any aspiration. A patient may aspirate without coughing or giving any other external sign that food has entered the airway. Aspiration is a symptom of a swallowing disorder. This necessitates an assessment of the exact nature of the anatomic or physiologic swallowing problem, which results in the aspiration.
As with all rehabilitation services, there must be a reasonable expectation that the patient will make material improvement within a reasonable period of time.
Professional Services Services are sometimes performed by SLPs, occupational therapists, and physical therapists, in concert with other health professionals. Services are often performed as a team with each member performing unique roles, which do not duplicate services of others. Services may include, but are not limited to, the following example:
EXAMPLE: One professional assisting with positioning, adaptive self help devices, inhibiting abnormal oromotor and/or postural reflexes while another professional is addressing specific exercises to improve oromotor control, determining appropriate food consistency form, and assisting the patient in difficulty with muscular movements necessary to close the buccal cavity or shape food in the mouth in preparation for swallowing. Another professional might be addressing a different role, such as increasing muscle strength, sitting balance, and head control.
Services of Speech-Language Pathology Support Personnel
Services of Speech-Language Pathology assistants are not recognized for Medicare coverage. Services provided by Speech-Language Pathology assistants, even if they are licensed to provide services in their states, will be considered unskilled services and denied as not reasonable and necessary if they are billed as therapy services.
Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.
ASHA Draft, June 24, 1999; To CIGNA Medicare, North Carolina
Aviv JE, Murry T, Zschommler A, Cohen M, Gartner C. Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST): Patient Characteristics and Analysis of Safety in 1340 Consecutive Examinations. Ann Otol Rhino Laryngol. 2005 Mar; 114(3):173-6.
Aviv, J., et al., The Safety of Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST): An Analysis of 500 Consecutive Evaluations, Dysphagia, 15:39-44 (2000).
Consultants in Otolaryngology and Speech-Language Pathology
Empire Medicare Services Medical Policy
Logemann JA (1985). The Diagnosis and Treatment of Dysphagia: An Inservice Training Manual. Northwestern University, Evanston, IL.
Langmore SE, Schatz K, Olsen N. Endoscopic and Videofluoroscopic Evaluations of Swallowing and Aspiration. Ann Otal Rhinol Laryngol. 1991;100:678-681.
Langmore SE. Fiberoptic Endoscopic Examination of Swallowing Safety: A New Procedure. Dysphagia 1988;2:216-219.
Veritus Medicare Services Local Coverage Determination: VitalStim Therapy
Wyngarden J, Smith Jr., L, Bennett J, et al. (1992) Textbook of Medicine. WB Saunders Company, New York pp. 623.
Xact Medicare Medical Review Policy Template Model Policy (FEESST)
Ali, GN, Wallace, KL, Laundl, TM et al. Predictors of outcome following cricopharyngeal disruptions for pharyngeal dsyphagia. Dysphagia 1997;12: 133-139.
Bidus KA, Thomas GR, Ludlow,CL. Effects of adductor muscle stimulation on speech in abductor spasmodic dysphonia. Laryngoscope 2000;110: 1943-1949.
Burnett TA, Mann E, Cornell SA, Ludlow CL. Laryngeal elevation achieved by neuromuscular stimulation at rest. Journal of Applied Physiology 2003;94: 128-134.
Burnett TA, Mann EA, Stoklosa JB, Ludlow CL. Self-triggered functional electrical stimulation during swallowing. J Neurophysiol 2005;94: 40114018.
CMS Pub.100-3, Medicare National Coverage Determinations Manual, Chap.1, § 170.3, describes speech-language pathology services related to dysphagia.
Davis FA (2001).Tabor' Cyclopedic Medical Dictionary 19th edition.
Freed ML, Freed L, Chatburn RL, Christian M. Electrical stimulation for swallowing disorders caused by stroke. Respiratory Care 2001;46(5):466471.
Grill WM, Foreman R, Ludlow, CL, Buller J . Emerging clinical applications: What wonders the future brings. Journal of Rehabilitation Research and Development 2001;38: 641-653.
Grill, WM, Craggs, MD, Foreman, R. et al. ( November/December 2001). Emerging clinical applications of electrical stimulation: opportunities for restoration of function. Journal of Rehabilitation Research and Development ( November/December 2001);38: No. 6.
Hamdy S, Jilani S, Price V, Parker C, Hall N, Power M. Modulation of human swallowing behavior by thermal and chemical stimulation in health and after brain injury. Neurogastroenterol Motil 2003;15(1):6977.
Hamdy S, et al. Recovery of Swallowing After Dysphagic Stroke Relates to Functional Reorganization in the Intact Motor Cortex. Gastroenterology 1998;115: 1104-1112.
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdidx_addenda08.pdf
http://www.accessdata.fda.gov
Humbert, IA, Ludlow CL. (2004, March 16). Electrical Stimulation Aids Dysphagia. The ASHA Leader, pp. 1, 23.
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. Submitted 23 March 2006; accepted in final form 18 July 2006.
Jafari S, Prince RA, Kim DY, Paydarfar D: Sensory regulation of swallowing and airway protection: a role for the internal superior laryngeal nerve in humans. J Physiol 2003;550(Pt 1):287304.
Kanaya F, et al. Effect of Electrostimulation on Denervated Muscle. Clinical Orthopaedics and Related Research. 1992; 282:296-301.
Leelamanit V, Limsakul C, Geater A. Synchronized electrical stimulation in treating pharyngeal dysphagia. Laryngoscope 2002;112(12):22042210.
Logemann JA. Evaluation and Treatment of Swallowing Disorders. 2nd Edition PRO-ED and International Publisher 8700 Shoal Creek Boulevard Austin, TX 78757-6897 © 1998 by PRO-ED, Inc. (1998).
Logemann JA. Approaches to management of disordered swallowing. Bailliere's Clinical Gastroenterology.1191; 5:269-280.
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. 2006 May 23.
Ludlow CL, Humbert IJ, Poletto CJ, Saxon KG, Kearney PR, Crujido L, Sonies B. The Use of Coordination Training for the Onset of Intramuscular Stimulation in Dysphagia.
10th Annual Conference of the International FES Society July 2005 Montreal, Canada.
Ludlow CL: Physiological effects of surface electrical stimulation vs. intramuscular stimulation on swallowing in chronic pharyngeal dysphagia. Presented at the Charleston Swallowing Conference, Charleston, SC, October 6, 2005.
Ludlow CL, Bielamowicz S, Daniels Rosenberg M, et al. Chronic intermittent stimulation of the thyroarytenoid muscle maintains dynamic control of glottal adduction. Muscle Nerve 2000;23: 44-57.
Ludlow C, Hang C, Bielamowicz S, et al. Three-dimensional changes in the upper airway during neuromuscular stimulation of laryngeal muscles. Artificial Organs 1999; 23:463-465.
Mann EA, Burnett T, Cornell S. The effect of neuromuscular stimulation of the genioglossus on the hypopharyngeal airway. Laryngoscope 2002; 112, 351-356.
Martin-Harris, B., Logemann, J.A., McMahon, S., Schleicher, M. & Sandidge, J. (2000) Clinical Utility of the modified barium swallow. Dysphagia, 15, 136-141;
Murray, J. (1999). A Manual of Dysphagia Assessment in Adults. San Diego: Singular Publishing Group, Inc., pp. 113-114.
Park CL, O’Neill PA, Martin DF. A pilot exploratory study of oral electrical stimulation on swallow function following stroke: An innovative technique. Dysphagia 1997; 12(3):161-166.
Perlman, AD ,Konrad, Schulze-Delrieu, S. Deglutition And Its Disorders, Anatomy, Physiology, Clinical Diagnosis And Management, Edition 1, © 1997.
Power M, Fraser C, Hobson A, Rothwell JC, Mistry S, Nicholson DA, Thompson DG, Hamdy S: Changes in pharyngeal corticobulbar excitability and swallowing behavior after oral stimulation. Am J Physiol Gastrointest Liver Physiol 2004;286(1):G45G50.
Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia 1996;11(2):9398.
Wijting Y, Freed ML. VitalStim Therapy Training Manual. Hixson, TN: Chattanooga Group, 2003.
Yokoyama M, et al. Role of Laryngeal Movement and Effect of Aging on Swallowing Pressure in the Pharynx and Upper Esophageal Sphincter. Laryngoscope March 2000;110 (3): 434-439.
Advisory Committee Meeting Notes
Aviv JE, Murry T, Zschommler A, Cohen M, Gartner C. Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST): Patient Characteristics and Analysis of Safety in 1340 Consecutive Examinations. Ann Otol Rhino Laryngol. 2005 Mar; 114(3):173-6.
Aviv, J., et al., The Safety of Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST): An Analysis of 500 Consecutive Evaluations, Dysphagia, 15:39-44 (2000).
Consultants in Otolaryngology and Speech-Language Pathology
Empire Medicare Services Medical Policy
Logemann JA (1985). The Diagnosis and Treatment of Dysphagia: An Inservice Training Manual. Northwestern University, Evanston, IL.
Langmore SE, Schatz K, Olsen N. Endoscopic and Videofluoroscopic Evaluations of Swallowing and Aspiration. Ann Otal Rhinol Laryngol. 1991;100:678-681.
Langmore SE. Fiberoptic Endoscopic Examination of Swallowing Safety: A New Procedure. Dysphagia 1988;2:216-219.
Veritus Medicare Services Local Coverage Determination: VitalStim Therapy
Wyngarden J, Smith Jr., L, Bennett J, et al. (1992) Textbook of Medicine. WB Saunders Company, New York pp. 623.
Xact Medicare Medical Review Policy Template Model Policy (FEESST)
Ali, GN, Wallace, KL, Laundl, TM et al. Predictors of outcome following cricopharyngeal disruptions for pharyngeal dsyphagia. Dysphagia 1997;12: 133-139.
Bidus KA, Thomas GR, Ludlow,CL. Effects of adductor muscle stimulation on speech in abductor spasmodic dysphonia. Laryngoscope 2000;110: 1943-1949.
Burnett TA, Mann E, Cornell SA, Ludlow CL. Laryngeal elevation achieved by neuromuscular stimulation at rest. Journal of Applied Physiology 2003;94: 128-134.
Burnett TA, Mann EA, Stoklosa JB, Ludlow CL. Self-triggered functional electrical stimulation during swallowing. J Neurophysiol 2005;94: 40114018.
CMS Pub.100-3, Medicare National Coverage Determinations Manual, Chap.1, § 170.3, describes speech-language pathology services related to dysphagia.
Davis FA (2001).Tabor' Cyclopedic Medical Dictionary 19th edition.
Freed ML, Freed L, Chatburn RL, Christian M. Electrical stimulation for swallowing disorders caused by stroke. Respiratory Care 2001;46(5):466471.
Grill WM, Foreman R, Ludlow, CL, Buller J . Emerging clinical applications: What wonders the future brings. Journal of Rehabilitation Research and Development 2001;38: 641-653.
Grill, WM, Craggs, MD, Foreman, R. et al. ( November/December 2001). Emerging clinical applications of electrical stimulation: opportunities for restoration of function. Journal of Rehabilitation Research and Development ( November/December 2001);38: No. 6.
Hamdy S, Jilani S, Price V, Parker C, Hall N, Power M. Modulation of human swallowing behavior by thermal and chemical stimulation in health and after brain injury. Neurogastroenterol Motil 2003;15(1):6977.
Hamdy S, et al. Recovery of Swallowing After Dysphagic Stroke Relates to Functional Reorganization in the Intact Motor Cortex. Gastroenterology 1998;115: 1104-1112.
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdidx_addenda08.pdf
http://www.accessdata.fda.gov
Humbert, IA, Ludlow CL. (2004, March 16). Electrical Stimulation Aids Dysphagia. The ASHA Leader, pp. 1, 23.
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. Submitted 23 March 2006; accepted in final form 18 July 2006.
Jafari S, Prince RA, Kim DY, Paydarfar D: Sensory regulation of swallowing and airway protection: a role for the internal superior laryngeal nerve in humans. J Physiol 2003;550(Pt 1):287304.
Kanaya F, et al. Effect of Electrostimulation on Denervated Muscle. Clinical Orthopaedics and Related Research. 1992; 282:296-301.
Leelamanit V, Limsakul C, Geater A. Synchronized electrical stimulation in treating pharyngeal dysphagia. Laryngoscope 2002;112(12):22042210.
Logemann JA. Evaluation and Treatment of Swallowing Disorders. 2nd Edition PRO-ED and International Publisher 8700 Shoal Creek Boulevard Austin, TX 78757-6897 © 1998 by PRO-ED, Inc. (1998).
Logemann JA. Approaches to management of disordered swallowing. Bailliere's Clinical Gastroenterology.1191; 5:269-280.
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. 2006 May 23.
Ludlow CL, Humbert IJ, Poletto CJ, Saxon KG, Kearney PR, Crujido L, Sonies B. The Use of Coordination Training for the Onset of Intramuscular Stimulation in Dysphagia.
10th Annual Conference of the International FES Society July 2005 Montreal, Canada.
Ludlow CL: Physiological effects of surface electrical stimulation vs. intramuscular stimulation on swallowing in chronic pharyngeal dysphagia. Presented at the Charleston Swallowing Conference, Charleston, SC, October 6, 2005.
Ludlow CL, Bielamowicz S, Daniels Rosenberg M, et al. Chronic intermittent stimulation of the thyroarytenoid muscle maintains dynamic control of glottal adduction. Muscle Nerve 2000;23: 44-57.
Ludlow C, Hang C, Bielamowicz S, et al. Three-dimensional changes in the upper airway during neuromuscular stimulation of laryngeal muscles. Artificial Organs 1999; 23:463-465.
Mann EA, Burnett T, Cornell S. The effect of neuromuscular stimulation of the genioglossus on the hypopharyngeal airway. Laryngoscope 2002; 112, 351-356.
Martin-Harris, B., Logemann, J.A., McMahon, S., Schleicher, M. & Sandidge, J. (2000) Clinical Utility of the modified barium swallow. Dysphagia, 15, 136-141;
Murray, J. (1999). A Manual of Dysphagia Assessment in Adults. San Diego: Singular Publishing Group, Inc., pp. 113-114.
Park CL, O’Neill PA, Martin DF. A pilot exploratory study of oral electrical stimulation on swallow function following stroke: An innovative technique. Dysphagia 1997; 12(3):161-166.
Perlman, AD ,Konrad, Schulze-Delrieu, S. Deglutition And Its Disorders, Anatomy, Physiology, Clinical Diagnosis And Management, Edition 1, © 1997.
Power M, Fraser C, Hobson A, Rothwell JC, Mistry S, Nicholson DA, Thompson DG, Hamdy S: Changes in pharyngeal corticobulbar excitability and swallowing behavior after oral stimulation. Am J Physiol Gastrointest Liver Physiol 2004;286(1):G45G50.
Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia 1996;11(2):9398.
Wijting Y, Freed ML. VitalStim Therapy Training Manual. Hixson, TN: Chattanooga Group, 2003.
Yokoyama M, et al. Role of Laryngeal Movement and Effect of Aging on Swallowing Pressure in the Pharynx and Upper Esophageal Sphincter. Laryngoscope March 2000;110 (3): 434-439.
This policy does not reflect the sole opinion of the contractor or contractor medical director (CMD). Although the final decision rests with the contractor, this policy was developed in consideration of input from relevant interested parties, including other contractors, CMD workgroup discussions and communication, and correspondence with medical societies, industry, and providers.
Start Date of Comment Period
05/30/2007
End Date of Comment Period
07/16/2007
Start Date of Notice Period
08/03/2007
Revision History Number
#6
Revision History Explanation
*#7. 10/01/2011, 2011 ICD-9 code update, added ICD-9 code 784.52;
#6 09/21/2008 Annual review. No limitations changed. No notice necessary, none given.
#5 08/03/2007. Final Notification with changes made due to comments received from provider community.
#4 05/30/2007. Reorganization of material already present in this LCD, expansion/clarification of the language regarding non-coverage of electrical stimulation and deep pharyngeal stimulation. CPT code 92700 added.
04/03/2007 LCD not showing on CMS site. Reloaded. No content changes made.
07/12/2006 ICD-9 codes 434.00 - 434.91 have been added to final LCD. Verbiage in skilled level of care has been changed.
05/16/2006 Substantive changes are made in the list of indications with
expansion/clarification of the language added to the limitations section clarifying that billing electrical stimulation (a non-covered service) in addition to the reasonable and necessary standard of care dysphagia treatment.
Based upon analysis of claims data, research and evidence based practice guidelines, CMS has identified conditions and complexities that will be excepted from caps. For additional information on Medicare requirements for therapy cap exceptions see: http://www.cms.hhs.gov/Transmittals/downloads/R855CP.pdf.
For all therapy services, including those provided before and after a cap exception is allowed, payment requires that documentation supports the medical necessity of the services. (Medicare Claims Processing Manual, Chapter 5 section C1).
Outpatient Therapy Caps are effective January 1, 2006.CMS citations were updated to reflect the removal of the therapy cap moratorium effective January 1, 2006. Additional information is added under the evaluation and re-evaluation sections. The “Limitations" section is revised by deleting the requirement for a physician to evaluate the patient prior to a dysphagia evaluation.
9/26/2005 Reorganization of material already present in this LCD, expansion/clarification of the language regarding various testing performed to determine the extent of the dysphsgia (no new limitations added), update to reflect changes in coverage provision (CMS Pub 100-02, Chapter 15, Section 220-230)changes to coverage of SLP assistants and/or aides) Addition of Revenue codes 0444 and 075X.
This LCD was converted from an LMRP on 9/23/2004.
CMS Manual updates completed 11/15/2004.
Update of the HCPCS codes relavent to this service 11/15/2004.
7/2/2006 - The description for Bill code 14 was changed
09/03/2007 - This policy was updated by the ICD-9 2007-2008 Annual Update.
2/18/2008 - The description for Bill code 21 was changed
2/11/2009 - Effective November 5, 2007 WPS assumed the Mutual of Omaha Part A (FI) business. This LCD has been modified retroactively to reflect the business name change. No other changes were made, and the LCD content has not changed.
08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update.
04/19/2010—In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
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 14 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 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 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 - Revenue code 0759 was deleted
02/21/2011 — In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
Reason for Change
#6 09/21/2008 Annual review. No limitations changed. No notice necessary, none given.
#5 08/03/2007. Final Notification with changes made due to comments received from provider community.
#4 05/30/2007. Reorganization of material already present in this LCD, expansion/clarification of the language regarding non-coverage of electrical stimulation and deep pharyngeal stimulation. CPT code 92700 added.
04/03/2007 LCD not showing on CMS site. Reloaded. No content changes made.
07/12/2006 ICD-9 codes 434.00 - 434.91 have been added to final LCD. Verbiage in skilled level of care has been changed.
05/16/2006 Substantive changes are made in the list of indications with
expansion/clarification of the language added to the limitations section clarifying that billing electrical stimulation (a non-covered service) in addition to the reasonable and necessary standard of care dysphagia treatment.
Based upon analysis of claims data, research and evidence based practice guidelines, CMS has identified conditions and complexities that will be excepted from caps. For additional information on Medicare requirements for therapy cap exceptions see: http://www.cms.hhs.gov/Transmittals/downloads/R855CP.pdf.
For all therapy services, including those provided before and after a cap exception is allowed, payment requires that documentation supports the medical necessity of the services. (Medicare Claims Processing Manual, Chapter 5 section C1).
Outpatient Therapy Caps are effective January 1, 2006.CMS citations were updated to reflect the removal of the therapy cap moratorium effective January 1, 2006. Additional information is added under the evaluation and re-evaluation sections. The “Limitations" section is revised by deleting the requirement for a physician to evaluate the patient prior to a dysphagia evaluation.
9/26/2005 Reorganization of material already present in this LCD, expansion/clarification of the language regarding various testing performed to determine the extent of the dysphsgia (no new limitations added), update to reflect changes in coverage provision (CMS Pub 100-02, Chapter 15, Section 220-230)changes to coverage of SLP assistants and/or aides) Addition of Revenue codes 0444 and 075X.
This LCD was converted from an LMRP on 9/23/2004.
CMS Manual updates completed 11/15/2004.
Update of the HCPCS codes relavent to this service 11/15/2004.
7/2/2006 - The description for Bill code 14 was changed
09/03/2007 - This policy was updated by the ICD-9 2007-2008 Annual Update.
2/18/2008 - The description for Bill code 21 was changed
2/11/2009 - Effective November 5, 2007 WPS assumed the Mutual of Omaha Part A (FI) business. This LCD has been modified retroactively to reflect the business name change. No other changes were made, and the LCD content has not changed.
08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update.
04/19/2010—In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
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 14 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 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 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 - Revenue code 0759 was deleted
02/21/2011 — In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
10/01/2010
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