Tuesday, March 21, 2017

CPT g0180 - Care plan oversight services



Care Plan Oversight Services


Care Plan Oversight (CPO) is physician supervision of patients under either the home health or hospice benefit where the patient requires complex or multi-disciplinary care requiring ongoing physician involvement. Medicare does not pay for care plan oversight services for nursing facility or skilled nursing facility patients.

Separate payment is allowed for the services involved in physician certification/re-certification and development of a plan of care for Medicare covered home health services.

Submit HCPCS code G0179 for re-certification after a patient has received services for at least 60 days (or one certification period). HCPCS code G0179 may be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.

Submit HCPCS code G0180 when the patient has not received Medicare covered home health services for at least 60 days. The initial certification (HCPCS code G0180) cannot be filed on the same date of service as the supervision service HCPCS codes (G0181 or G0182).
HCPCS Codes

G0179: MD re-certification HHA PT

G0180: MD certification HHA patient

G0181: Home health care supervision

G0182: Hospice care supervision

How to submit a claim

Submit CPT codes 99201-99263 and 99281-99357 only when there has been a face-to-face meeting/encounter

HHA / Hospice Provider Number: The requirement to include the HHA or Hospice provider number on a care plan oversight claim for HCPCS codes G0181 and G0182 is waived until further notice, and as a result, claims submitted with the number will be rejected.

Dates of service: for HCPCS codes G0181 and G0182, submit the first and last date during which documented care planning services were actually provided during the calendar month.

Do not submit the first and last calendar date of the month unless services were provided on those dates)
Submit the claim after the end of the month in which the service is performed

Report care planning only once per calendar month

Report only one month's services per line item

Dates of service: for HCPCS codes G0179 and G0180, submit the date physician signed the certification or re-certification

Documentation

Claims for care plan oversight services will be denied when review of the beneficiary claims history fails to identify a covered physician service requiring a face-to-face encounter by the same physician during the six months preceding the provision of the first care plan oversight service
Medical records for these service must indicate:
The physician spent 30 minutes or more for countable care planning activities
The specific service furnished, including the date and length of time

Monday, March 20, 2017

cpt 66821 - YAG capusulotomy surgery

CPT/HCPCS Codes

Group 1 Codes:

66821 After cataract laser surgery

Coverage Indications, Limitations, and/or Medical Necessity

Indications

YAG laser capsulotomies (YAG) are performed in cases of opacification of the posterior capsule, generally no less than 90 days following cataract extraction. YAG performed less than 90 days following cataract extraction should meet both the indications and limitations of this LCD. The percentage of patients having this procedure varies greatly among ophthalmologists. Diagnosis of functional visual impairment due to capsular opacification is based on clinical judgment regarding one or more of the following:

Visual loss and/or symptom of glare (visual acuity 20/30 or worse under Snellen conditions, using contrast sensitivity, or simulated glare testing);
Symptoms of decreased contrast;
Amount of posterior capsular opacification; or
Other possible causes of decreased vision following cataract surgery.

Limitations 

This procedure will not be covered within three months post cataract surgery unless justified by one of the following indications:

Posterior capsular plaque/opacity which cannot be safely removed during primary phacoemulsification cataract procedure
Capsular block during which cataract remnants and fluid become trapped within the lens capsule and addressed with YAG laser posterior capsulotomy
Contraction of the posterior capsule with displacement of the intraocular lens



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.
N/A

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the 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.

N/A


ICD-10 Codes that Support Medical Necessity

ICD-10 CODE DESCRIPTION

H26.491 - H26.493 - Opens in a new window Other secondary cataract, right eye - Other secondary cataract, bilateral
T85.21XA Breakdown (mechanical) of intraocular lens, initial encounter
T85.29XA Other mechanical complication of intraocular lens, initial encounter

Friday, March 10, 2017

CPT 19318 - Surgery reduction mammplasty

CPT/HCPCS Codes

19318 Reduction of large breast

Coverage Indications, Limitations, and/or Medical Necessity

Background:

Reduction mammaplasty is the surgical removal of a substantial portion of the breast, including the skin and underlying glandular tissue, until a clinically normal size is obtained.

Reduction mammaplasty is performed to reduce the size of the breast/breasts and:

help ameliorate symptoms caused by hypertrophy or

to reduce the size of a contralateral breast to bring it into symmetry with a breast reconstructed after cancer surgery.

Indications:

Reduction mammaplasty is considered medically necessary:

When the patient has significant symptoms that have interfered with normal daily activities despite conservative management for at least 6 months, including at least one of the following criteria:

History of back and/or shoulder pain which adversely affects activities of daily living (ADLs) unrelieved by, e.g.: conservative analgesia (e.g., such as NSAID, compresses, massage, etc.), supportive measures (e.g., such as garments, back brace, etc.), physical therapy, correction of obesity.

History of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with medication and/or significant restriction of activity (e.g.: signs and symptoms of ulnar paresthesias evidenced by nerve conduction studies, cervicalgia, torticollis, or acquired kyphosis).

Signs and symptoms of: intertrigonous maceration and/or infection of the inframammary skin (e.g., hyperpigmentation, bleeding, chronic moisture, and evidence of skin breakdown refractory to dermatologic measures), or shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by appropriate supporting garment.

AND:

The amount of breast tissue removed (by pathology report) is at least 400 grams per breast.


When the patient’s normal breast is reduced to achieve symmetry with a breast reconstructed after cancer surgery.

Limitations

Cosmetic surgery to reshape the breasts and surrounding tissue to improve appearance is not a Medicare benefit. The use of such CPT codes as 12034 and 12035, 14001, 15830, 15836, 15839, 15876 through 15879, and 19350 associated with reshaping will be considered part of (bundled into) the primary reduction mammaplasty procedure.

Indications of coverage must be met.




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.
999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the 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.

N/A

Friday, March 3, 2017

cpt 88341, 88342 - Lyncy syndrome

CPT/HCPCS Codes  Group 1 Codes:

81210 Braf gene

81292 - 81300 Mlh1 gene full seq - Msh6 gene dup/delete variant

81317 - 81319 Pms2 gene full seq analysis - Pms2 gene dup/delet variants

81403 Mopath procedure level 4


Group 2 Codes:


81301 Microsatellite instability

88341 Immunohisto antibody slide

88342 Immunohisto antibody stain

88344 Immunohisto antibody slide
Coverage Guidance

Background

I. Lynch Syndrome (LS)

This policy limits Lynch syndrome (LS) genetic testing to a stepped approach for Microsatellite Instability and Immunohistochemistry (MSI/IHC) screening, BRAF gene mutation, MLH1 gene promoter hypermethylation and targeted mismatch repair (MMR) germ-line gene testing to patients suspected of having LS. 

Most colorectal cancer is caused by non hereditary somatic mutations. Individuals with LS (aka hereditary nonpolyposis colorectal cancer (HNPCC)) are predisposed to cancer due to having inherited or de novo germ-line mutations in DNA repair genes, that result in an accelerated accumulation of somatic mutations. LS, the most common hereditary cause of colorectal cancer, accounts for 2-3% of all colorectal cancers, followed by familial adenomatous polyposis (FAP) which accounts for <1 and="" colorectal="" div="" frequency="" is="" malignancies="" mutyh-associated="" nbsp="" occurrence="" of="" polyposis="" rare.="" very="" whose="">

LS is an autosomal dominant familial cancer syndrome caused by mutations in multiple susceptibility genes (e.g., MLH1, MSH2, MSH6, PMS2, EPCAM), and is associated with an increased lifetime risk for colorectal cancer (CRC) and other malignancies within the tumor spectrum including at least endometrial, ovarian, gastric, small bowel, urothelial, hepatobiliary tract, sebaceous and pancreatic cancers. Current literature suggests LS annually affects 28,000 individuals. In individuals with LS, the lifetime risk of colon cancer may be as high as 75% by the age of 70 years, with an average age onset of 45 years in MLH1 and MSH2 mutation carriers. While the incidence of adenomas in individuals with LS is similar to that in the general population, the high rate of colorectal cancer is due to an acceleration of the adenoma to carcinoma sequence. 

Cancer risks associated with LS are largely derived from family studies. Mutations in MLH1 and MSH2 account for 70-90% of families with LS. The risk of colon and endometrial cancer is less in MSH6 and PMS2 mutation carriers, although the cancer risk may not be lower for MSH6 carriers if one takes the data out to age 80. While individuals with a single MLH1, MSH2, MSH6 and PMS2 mutation develop cancers in mid-life, individuals with biallelic MLH1, MSH2, MSH6 and PMS2 mutations have a distinctive phenotype and tumor spectrum, and often develop cancer as early as the first decade of life. 

First-degree relatives of mutation carriers have a 50% probability of having the same germ-line mutation. Despite the high penetrance of CRC and endometrial cancer and recommendations of consideration for screening unaffected first-degree relatives following diagnosis of an LS proband, testing of genetic carriers who are unaffected with a Lynch related cancer is not a Medicare benefit, and is statutorily excluded from coverage. 

II. Testing Strategy for Patients with Personal History of Colorectal Cancer

Step 1: Patient selection 

Patients with colorectal and/or endometrial cancer suspected of LS must undergo a comprehensive review of physical findings and a complete personal and family history. 

In 1989, the Amsterdam criteria defined what is known as Hereditary Non-polyposis Colon Cancer Syndrome, and in 1999, the criteria were revised to include extra-colonic tumors (Table 1). Today we know there are two distinct groups comprising HNPCC: those with hereditary DNA mismatch repair germ-line mutations, known as Lynch Syndrome, and those with normal DNA mismatch repair, known as Familial Colorectal Cancer Type X. 

Table 1. Amsterdam Criteria II (ACII)

There should be at least three relatives with CRC or with a Lynch syndrome-associated cancer: endometrial, small bowel, ureter or renal pelvis cancer.
One relative should be a 1st-degree relative of the other two,
At least two successive generations should be affected,
At least one tumor should be diagnosed before age 50 years,
FAP should be excluded in the CRC case, if any,
Tumors should be verified by histopathological exam

Approximately 50% of families meeting the ACII criteria have a mutation in an MMR gene. However, these criteria are very stringent and miss as many as 68% of patients with LS. 

In 1997, the Bethesda guidelines were developed to identify individuals with CRC who should be tested for MSI. In 2002, the guidelines were revised (Table 2) to clarify selection criteria for microsatellite instability (MSI) testing and mismatch repair (MMR) protein expression by immunohistochemistry (IHC). Screening tumors of patients meeting the Bethesda guidelines for MSI was shown to be cost-effective with newly diagnosed CRC. 

Table 2 - Revised Bethesda Guidelines 

Meeting any of the following are sufficient for consideration of MSI/IHC testing
CRC diagnosed under age 50
Presence of synchronous, or metachronous CRC or other Lynch-associated tumor, regardless of age
CRC with MSI-H histology diagnosed in an individual who is < age 60
CRC diagnosed with one or more 1st-degree relatives with a Lynch-related tumor, with one of the cancers diagnosed under age 50
CRC diagnosed in two or more 1st- or 2nd-degree relatives with a Lynch-related tumor, regardless of age

If a patient meets standards for LS testing in Step 1, (i.e., meets ACII or Revised Bethesda guidelines), the physician should proceed to Step 2 and 3. 

Step 2: Immunohistochemistry (IHC) testing for LS Screening

The use of IHC to detect loss of DNA mismatched repair (MMR) protein expression complements MSI to screen patients for defective MMR (dMMR), including both sporadic dMMR and LS dMMR. IHC allows detection of loss of protein expression for the MLH1, MSH2, MSH6 and PMS2 genes. Loss of MMR protein expression is detected by the absence of nuclear staining in the tumor cells and the presence of nuclear staining in lymphocytes and normal colon crypt epithelial cells. 

The MMR proteins are present as heterodimers ( MLH1 pairs with PMS2, and MSH2 pairs with MSH6). Knowledge of MMR protein expression loss patterns allows a logical and cost effective “directed” testing appropriate for germ-line mutation analysis. As a general rule, loss of expression of MLH1 or MSH2 is associated with loss of their partners. For example, mutation of the MLH1 gene generally leads to loss of expression of both the MLH1 and PMS2 proteins. However, loss of PMS2 or MSH6 due to a germ-line mutation is associated only with loss of the mutated protein. For example, mutation of the PMS2 gene leads to loss of expression of only the PMS2 protein. 

If IHC is done first and is abnormal, MSI testing is not warranted. Often IHC is done first because of its rapid turn-around and minimal amount of tissue required. If IHC demonstrates loss of protein expression for the MLH1, MSH2, MSH6 and PMS2 genes, the following test results direct further testing:
MLH1 loss by IHC, test for BRAF gene mutation (Step 4) or test for MLH1 promoter, (Step 5)
MSH2/MS6 loss by IHC, perform MSH2 germ-line testing (Step 6)

If IHC test results are normal, there remains a small chance of high levels of microsatellite instability (MSI-H), so both IHC and MSI would be needed to rule out LS in a clinically suspicious setting.

Step 3: Microsatellite Instability (MSI) Analysis for LS Screening

MSI analysis for screening LS microsatellites are short repeated segments of DNA spread throughout the genome. Under normal conditions, the MMR gene complex (MLH1, MSH2, MSH6 and PMS2 genes) corrects mismatched base pairs that occur during the final stage of DNA replication. When the MMR complex is functioning normally, all cells show an identical pattern of microsatellite lengths. When the MMR complex is non-functioning, due to two hits of any type, random mutations accumulate in microsatellites, leading to differences in microsatellite lengths (microsatellite instability, MSI). Therefore, MSI indicates loss-of-function defects in a MMR protein, which may be due to somatic mutations, germ-line MMR gene mutations, allelic loss, or to epigenetic down-regulation. MSI is usually associated with absence of protein expression of one or more of the MMR proteins ( MLH1, MSH2, MSH6M and PMS2). 

DNA from paraffin-embedded tumor tissue and normal tissue or peripheral blood is used for MSI analysis. A microsatellite is considered unstable if the distribution of the tumor fragments differs from that of the normal tissue. Noncancerous tissue in individuals with LS does not show MSI because normal tissue is heterozygous for the germ-line mutation. 

Levels of MSI in colon tumors are classified as: 
MSI-H> - 30% or more of a tumor’s markers are unstable;
MSI-L - > one but < 30% of a tumor’s markers are unstable; 
MSS - no loci are unstable.

MSI-L and MSS indicates the MMR mechanism is functioning adequately. Virtually all CRC tumors from individuals with LS demonstrate MSI-H. However, MSI-H is NOT diagnostic of LS as MSI-H can be observed in roughly 15% of sporadic colorectal cancers. In other Lynch tumors, the % level of MSI-H is less consistent and is inadequately studied. 

As indicated above, MSI testing is not necessary if IHC demonstrates loss of protein expression for the MLH1, MSH2, MSH6 and PMS2 genes. If IHC test results are normal, there remains a small chance of high levels of microsatellite instability (MSI-H), so both IHC and MSI should be performed to rule out LS in a clinically suspicious setting such as meeting a Revised Bethesda guideline. Additionally, some individuals with MSH6 germ-line mutations do not manifest the MSI-H phenotype. This finding supports the diagnostic strategy to screen suspected LS patients with CRC by both MSI and IHC. Immunohistochemistry (IHC) can be used to identify whether the protein products of MLH1, MSH2, MSH6 and PMS2 genes are present or absent. Individuals with tumors that display high levels of MSI or loss of expression of MMR proteins by IHC are then referred for targeted germ-line mutation. 

Steps 4 and/or 5 apply only for tumors that are negative for MLH1 protein expression by IHC. 

Step 4: BRAF V600E (BRAF) Mutation Testing 

BRAF mutation testing and MLH1 promoter methylation studies distinguish between sporadic dMMR and LS dMMR. This is because BRAFM mutation and MLH1 PHM are very seldom seen in LS. BRAF mutation testing of the CRC tumor is associated with the presence of an epigenetic alteration (i.e., hypermethylation of MLH1) and either finding excludes germ-line MMR gene mutation (eg., LS). 

Step 5: MLH1 Promoter Hypermethylation ( MLH1 PHM)

The combination of MLH1 PHM and a BRAF mutation in tumors rules out LS and no further molecular analysis is warranted. Tumors with MLH1 PMH identify dMMR which will most often be sporadic, but its presence does not fully rule out LS. However, there have been rare reports of MLH1 hypermethylation as a second hit in LS and there are new reports of constitutional MLH1 methylation. As a rule, discovery of MLH1 PHM indicates the tumor is not due to Lynch syndrome. 

The following combinations of BRAF and MLH1 promoter methylation test results direct further testing in individuals with CRCs with loss of IHC expression of MLH1/PMS2:
If BRAF mutation is present, no further testing is medically necessary; LS is ruled out.
If BRAF mutation is absent, MLH1 promoter methylation testing is indicated and directs the following testing:
If MKH1 is hypermethylated, germline MLH1 is not medically necessary.
If the MLH1 promoter is hypermethylated and ACII if fulfilled, germ-line MLH1 may still be considered (2nd hit scenario). 
If the MLH1 promoter is normally methylated, and BRAF is negative for mutation then germ-line MLH1 testing is medically indicated. 


Note: There is variability in laboratory preference for BRAF and MLH1 promoter testing sequence. Although BRAF is generally cheaper and faster, some labs test MLH1 PHM first because it is more sensitive for detection of sporadic dMMR. 

In a study by Gausachs (2012), when MLH1 PHM testing is used in conjunction with BRAF mutation testing, the cost per additional mutation detected when using hypermethylation analysis was lower than that of BRAF and germinal MLH1 mutation analysis. Somatic hypermethylation of MLH1 is an accurate and cost-effective pre-screening method in the selection of patients that are candidates for MLH1 germ-line analysis when LS is suspected and MLH1 protein expression is absent.

Step 6: Targeted MMR ( MLH1, MSH2, MSH6 and PMS2 gene) Germ-line and EpCAMTesting

Step 6A: MLH1 Testing

When IHC shows loss of both MLH1 and PMS2, further genetic testing of PMS2 is not indicated, as no cases have been reported of a PMS2 germ-line mutation when IHC showed a loss of both MLH1 and PMS2. PMS2 mutations have only been detected when IHC shows a loss of PMS2 only. If MLH1 gene mutationgeme-line is positively identified, then LS is diagnosed and further testing of the patient is not medically necessary. 

Step 6B: MSH2 Testing

When IHC shows loss of MSH2 and MSH6, genetic testing should start with analysis of the MSH2 gene, given its frequency of germ-line mutation in LS. If MSH2 germ-line mutation is identified, then LS is diagnosed, and further testing of the patient is not medically necessary. 

However, if genetic testing for germ-line mutations in MSH2 is negative, analysis for deletion in the EpCAM gene should be performed (Step 7). If EpCAM is also negative, genetic testing of MSH6 should be performed (Step 6C). The presence of MSI and the loss of MSH2/MSH6 strongly indicate a MMR germ-line defect. 

Step 6C: MSH6 Testing

When IHC shows loss of just MSH6, it suggests a germ-line mutation in MSH6 and genetic testing of that gene is indicated. As previously noted, MSH6 CRC tumors can be MSI-H, MSI-L or MSS. This pitfall illustrates the utility of IHC for MMR protein expression. If MSH6 germ-line mutation is identified, then LS is diagnosed, and further testing of the patient is not medically necessary. 

Step 6D: PMS2Testing

If IHC shows PMS2 loss only, germ-line testing for PMS2 mutations is indicated. No cases of a PMS2 germ-line mutation have been identified after IHC showed a loss of both MLH1 and PMS2. If PMS2 germ-line mutation is identified, then LS is diagnosed, and further testing of the patient is not medically necessary.

Step 7: EpCAM Testing

Recently, deletions in a portion of the EpCAM gene were found in a subset of families with LS with a loss of MSH2 by IHC. A common deletion in the 3’ region of EpCAM causes somatic hypermethylation of MSH2, as the 2 genes are adjacent to one another on chromosome 2. Approximately 20% of patients with absence of MSH2 and MSH6 protein expression by IHC, but without MSH2 or MSH6 mutation, will have germ-line deletions in EpCAM. Early estimates suggest that germ-line mutations in EpCAM may account for approximately 6% of LS cases and possibly as high as 30% when IHC shows a loss of MSH2.

Note: Many labs incorporate EpCAM detection their MSH2 dup/deletion analysis. 


Indications

IHC and/or MSI Testing

LS tumor screening with IHC or MSI on colorectal and/or endometrial tumors is considered medically necessary and covered by Medicare for the following indications: 
Individual with colorectal or endometrial cancer whose family meets the ACII or revised Bethesda guidelines**, OR 
Individual with endometrial cancer diagnosed before age 50.

For coverage, the treating physician/pathologist is expected to follow the stepped approach outlined for LS screening and targeted MMR testing in this policy. Germ-line testing includes sequence and duplication-deletion analysis for a given gene. 

MMR Germline Gene Mutation Testing Exception

If a lab is unable to perform the stepped testing approach outlined in this LCD, multiple germ-line gene testing will be covered by Medicare only for one or more of the following findings:
MSI/IHC testing yields normal IHC and MSI-H, suggesting LS 
If tumor is not available or determined by a pathologist to be inadequate to assess DNA MMR deficiency by MSI or IHC, then MMR germ-line testing can be conducted on blood if the individual fulfills the ACII or revised Bethesda guidelines. 
CRC tumor diagnosis prior to Medicare eligibility AND tumor sample no longer available AND individual meets ACII or revised Bethesda guidelines or was diagnosed with endometrial cancer before 50 

If targeted gene testing is not possible, MLH1 and MSH2 testing should be performed first, since these two genes account for the majority of germ-line mutations. If no mutation is identified in MLH1 or MSH2, testing of MSH6 is indicated. If no mutation is identified in MSH6, testing of PMS2 may be considered. 

Testing for Known Familial Variant 

Testing for a specific known familial variant is considered medically necessary and covered only when the individual being tested has signs and symptoms of a Lynch-associated cancer AND has a blood relative with the specific disease-causing mutation for LS.


Limitations 

This LCD does not imply that testing family members of a known familial variant is not medically warranted. The scope of the Medicare benefit requires the beneficiary to have signs and symptoms of disease. Coverage of molecular testing for LS for carrier status or family studies is considered screening and is statutorily excluded from coverage.

Universal testing of CRC and endometrial cancers by MSI/MMR protein expression by IHC is not a Medicare benefit.




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.
999x Not Applicable




Revenue Codes:


Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the 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.

99999 Not Applicable

Sunday, February 26, 2017

CPT CODE 92526, 92610, 92611 - Dysphagia swallowing

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

92508 Speech/hearing therapy
92526 Oral function therapy
92610 Evaluate swallowing function
92611 Motion fluoroscopy/swallow
92612 Endoscopy swallow tst (fees)
92616 Fees w/laryngeal sense test

Evaluation of oral and pharyneal swallowing function (CPT 92610)

The evaluation of oropharyngeal swallowing dysfunction including the phases of oral preparatory, oral/voluntary and pharyngeal in reference to oral and motility problems in the oral cavity and pharynx.

The clinical examination may include:
a) history of patient's disorder and awareness of swallowing disorder, and indications of localization and nature of disorder;
b) medical status including nutritional and respiratory status;
c) oral anatomy/physiology (labial control, lingual control, palatal function);
d) pharyngeal function;
e) laryngeal function;
f) ability to follow directions; alertness
g) efforts and interventions used to facilitate normal swallow; (compensatory strategies such as chin tuck, dietary changes, etc.)
h) identifying symptoms during attempts to swallow


The clinical examination can be divided into two phases:

1. The preparatory examination with no swallow, and
2. The initial swallow examination with actual swallow while physiology is observed

Note: Based on the findings, an instrumental exam may be recommended.

Treatment of swallowing and dysfunctional or oral function for feeding (CPT 92526)

This involves the treatment for impairments/functional limitations of mastication, the preparatory phase, oral phase, pharyngeal stage, and esophageal phase of swallowing. Make appropriate recommendations regarding diet and compensatory techniques and instruct in direct/indirect therapies to facilitate oral motor control for feeding.

Coverage Indications, Limitations, and/or Medical Necessity

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, and encephalopathies. While dysphagia can afflict any age group, it most often appears among the elderly. Dysphagia services are covered under Medicare by therapists, regardless of the presence of a communication disability.

Indications

General Therapy Guidelines

The conditions of coverage and payment must be met as outlined in the Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 220.1.

Speech therapy services for dysphagia are either rehabilitative or maintenance related. The documentation must clearly indicate if skilled therapy services are being provided for rehabilitative purposes or maintenance. Rehabilitative therapy includes services designed to address recovery or improvement in function. Rehabilitative therapy services may be covered if the documentation indicates that the skills of the therapist are needed and are provided and if the documentation indicates by objective measurements that improvements are being made, or a decrease in severity is present, or rationalization for an optimistic outlook is present to justify continued treatment. For coverage requirements for maintenance related services, see number 7 below.

Dysphagia services are covered, provided such services are of a level of complexity and sophistication, or the patient’s condition is such that the services can be safely and effectively performed only by a licensed qualified therapist. Services normally considered to be a routine part of nursing care are not covered.

For rehabilitative therapy, the goal is for a patient to return to the highest level of function realistically attainable and within the context of the disability. The skills of the therapist may not necessarily be required to attain this goal but may be required initially to ensure safety, proper modality performance, etc.

Covered dysphagia services must relate directly and specifically to an active written treatment plan and must be reasonable and necessary to the treatment of the individual’s illness or injury. The plan of treatment should address specific therapeutic goals for which modalities and procedures are outlined in terms of type, frequency and duration. The plan of care must be certified/approved by the Physician/NPP.

In order for the plan of care to be covered, it must address a condition for which dysphagia services are an accepted method of treatment, as defined by standards of medical practice.

For rehabilitative therapy, there must be an expectation that the condition will improve significantly in a reasonable and generally predictable period of time based on the physician’s assessment of the patient’s rehabilitation potential, after any needed consultation with the qualified therapist. For maintenance therapy, the documentation must clearly indicate that:

the skills of the therapist must be necessary to establish a safe and effective maintenance program in connection with a specific disease state, or
the services required to maintain the patient’s current function or to prevent or to slow further deterioration are of such complexity and sophistication that the skills of a therapist are required, or

the particular patient’s special medical complications require the skills of a therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration.

The therapist must document the patient’s functional limitations in terms that are objective and measurable. The therapist must document the therapeutic short and long term goals in terms that are objective and measurable. Dysphagia services are not covered when the documentation fails to support that the functional ability or medical condition was impaired to the degree that it required the skills of a therapist.

Rehabilitative speech therapy services for dysphagia are not covered when the documentation indicates the patient has not reached the therapy goals and is not making significant improvement or progress, and/or is unable to participate and/or benefit from skilled intervention or refused to participate. Establishing or designing a maintenance program or instructing the patient or appropriate caregiver in a maintenance program is not covered if the specialized skill, knowledge and judgment of a therapist are not required. Performance of a maintenance program by the therapist is not covered if the maintenance procedures do not require the skills of a therapist or the patient’s medical complications are not complex to require the skills of a therapist to perform the maintenance procedures. The skills of a therapist are not generally required to maintain function. In addition, establishing, designing or performing a maintenance program is not covered if the patient would not benefit from it or refuses to participate.

Rehabilitative speech therapy services for dysphagia are not covered when the documentation indicates that a patient has attained the therapy goals or has reached the point where no further significant practical improvement can be expected.

The design of a maintenance regimen/home swallowing program to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease may be considered reasonable and necessary if the skills of the therapist are required. Limited services may be considered reasonable and necessary to establish and assist the patient and/or caregiver with the implementation of a maintenance program. No more than 2-4 visits for completion of the maintenance program and instruction of the patient and supportive personnel or family are considered medically necessary without significant documentation. Documentation must indicate that the maintenance program has been designed for the patient's level of function and instructions to the patient and supportive personnel have been completed for them to safely and effectively carry them out. The initiation of a maintenance program should occur early in a course of therapy.
Dysphagia services are not covered to treat Skilled Nursing Facility patients whose care can safely and effectively be rendered by the Skilled Nursing Facility’s trained professional staff.

Dysphagia services are not covered when a patient suffers a temporary loss or reduction of function and could reasonably be expected to improve spontaneously without the services of the therapist. For example, the patient with a TIA with swallowing deficits that are resolving.
Dysphagia services provided to screen patients who might need or benefit from dysphagia services intervention (i.e. screening) are not covered.
Dysphagia services visits would not be routinely covered on a daily basis through discharge. Normally, visit frequency would decrease as the patient’s condition improves.

Dysphagia services which are duplicative of other concurrent rehabilitation services are not covered.
Services which are related solely to specific employment opportunities (i.e., on-the-job training, work skills, or work settings) are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are not covered.

The educational component of treatment is included in the service described by the specific CPT code; therefore, there is no separate coverage for education.
Documentation of services is part of the coverage of the respective CPT; therefore, there is no separate coverage for time spent on documentation.
The ICD-10 coverage section of this LCD is meant to include 'functional' diagnoses. The functional diagnosis, not necessarily the clinical diagnosis, conveys coverage.

General Dysphagia Guidelines


If the documentation supports that the services required the skills of a therapist and that the skills of a therapist were provided, speech therapy services for dysphagia may be indicated for the following:

History of aspiration problems or aspiration pneumonia, or definite risk for aspiration, reverse aspiration, chronic aspiration, nocturnal aspiration, or aspiration pneumonia.
Nasal regurgitation, choking, frequent coughing up food during swallowing, wet or gurgly voice quality after swallowing liquids or delayed or slow swallow reflex.
Presence of oral motor disorder.

Impaired salivary gland performance and/or presence of local structural lesion in the pharynx resulting in marked oropharyngeal swallowing difficulties.

Dyscoordination, sensation loss, postural difficulties, or other neuromotor disturbances affecting oropharyngeal abilities necessary to close the buccal cavity and/or bite, chew, shape and squeeze the bolus into the upper esophagus, while protecting the airway.

Post-surgical reaction with specific signs, symptoms, and concerns supported in the documentation for the specific need of a qualified therapist to intervene.

Documented significant weight loss (5% in 1 month, 10% in 6 months) with documentation to support that the weight loss is directly related to reduced oral intake as a consequence of dysphagia, not merely reduced appetite (related to other medical/surgical illnesses, i.e. cachexia) or fluid shifting.

Existence of other conditions such as presence of tracheotomy or endotracheal tubes, ventilation management, nasogastric feeding or other enteral feeding, reduced or inadequate laryngeal elevation, labial closure, velopharyngeal closure, or pharyngeal peristalsis and cricopharyngeal dysfunction.

Dysphagia Evaluation


CPT 92610 - Evaluation of oral and pharyngeal swallowing
This evaluation is a clinical (usually bedside) one that does not involve the interpretation of dynamic radiologic studies or endoscopic studies.
The evaluation typically includes a bedside assessment of oral-motor functioning and signs and symptoms of pharyngeal dysphagia.
The evaluation is covered again after treatment has been initiated only if there is a change in the patient's overall condition of such significance that the plan of care cannot meet the beneficiary's goals with re-evaluation.
This code is an untimed code; therefore, only 1 unit is covered when reasonable and necessary.

Additional Documentation Requirements

History
Oral sensorimotor exam
Cervical auscultation
Positioning
Current eating status including onset and duration of problem
Clinical observations such as:
Presence of a feeding tube;
Paralysis; Oral, pharyngeal, laryngeal
Coughing or choking;
Oral motor structure and function;
Oral sensitivity;
Muscle tone;
Oropharyngeal reflexes;
Swallowing function;
Positioning;
Laryngeal function and vocal quality and loudness; and
Cognition and communication skills
Diagnosis that describes the phase of swallow affected
Recommendations for further assessment or treatment/intervention
Dysphagia Instrumental Assessment


An instrumental assessment (e.g. Modified Barium Swallow Study, Flexible Fiberoptic Endoscopic Evaluation of Swallowing) may be indicated for patients with suspected (e.g. observations by clinical or support personnel of choking with meals, excessive drooling, etc.), or who are at high risk for pharyngeal dysphagia. Dysphagia treatment may occur prior to the instrumental assessment. The final analysis and interpretation of a instrumental assessment should include a definitive diagnosis, identification of the swallowing phase(s) affected, and a recommended treatment plan, including compensatory swallowing techniques and/or postures and food and/or fluid texture modification. An instrumental assessment is not indicated if findings from the clinical evaluation fail to support a suspicion of dysphagia; or, when findings from the clinical evaluation suggest dysphagia but include either of the following: (1) the patient is unable to cooperate or participate in an instrumental evaluation; or (2) the instrumental examination would not change the clinical management of the patient. Absence of instrumental evaluation does not preclude the patient from receiving dysphagia treatment. An instrumental assessment is not covered as a screening tool and should be considered only if (a) an appropriate referral for dysphagia by a qualified clinician is made and (b) the dysphagia evaluation supports proceeding with an instrumental assessment.

CPT 92611 Motion fluoroscopic evaluation of swallowing function by cine or video recording
This assessment is covered one time after the therapist determines, based on the results of the initial evaluation (CPT 92610) that the patient requires and could benefit from further evaluation and treatment. This evaluation is not covered more than once unless the documentation supports there has been significant clinical change that would impact the course of therapy.

Goals for this evaluation include identifying structural causes of dysphagia, assessing the functional integrity of the oropharyngeal swallow, evaluating the risk of aspiration, and determining if the pattern of dysphagia is amenable to therapy. The effects of compensatory maneuvers and diet modification on aspiration prevention and/or bolus transport during swallowing are able to be studied radiographically to determine a safe diet and to maximize efficiency of the swallow.

This code is an untimed code, therefore, only 1 unit is covered when reasonable and necessary.
The patient’s medical record should show evidence that the referring/attending qualified clinician ordered this test.

If the plan of treatment by the treating therapist is based on the results of a report not issued by the treating therapist then the results of the test or the test report should be part of the medical record.
CPT 92612 - Flexible Fiberoptic Endoscopic Evaluation Of Swallowing By Cine Or Video Recording
Endoscopic evaluation of swallowing by cine or video recording (also called Fiberoptic Endoscopic Evaluation of Swallowing (FEES) utilizes the fiberoptic nasopharyngolaryngoscope to evaluate the pharyngeal swallow. Detailed information regarding swallowing function and related functions of structures within the upper aerodigestive tract are obtained. Therapeutic maneuvers are attempted during this examination to determine a safe diet and to maximize the efficiency of the swallow.
This assessment is covered one time after the therapist determines, based on the results of the initial evaluation (CPT 92610) that the patient requires and could benefit from further evaluation and treatment. This evaluation is not covered more than once unless the documentation supports there has been significant clinical change that would impact the course of therapy.

The clinician performing this service should be appropriately trained.

The patient’s medical record should show evidence that the referring/attending qualified clinician ordered this test.

This is an untimed code and is covered for only 1 unit when reasonable and necessary.
If the plan of treatment by the treating therapist is based on the results of a report not issued by the treating therapist then the results of the test or the test report should be part of the medical record.


Additional Documentation Requirements


Detailed findings of the endoscopic exam

CPT 92616 - Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing by cine or video recording
This procedure, known as FEESST, is a modification of FEES, with the addition of specialized equipment that quantifies the sensory threshold in the larynx. Velopharyngeal closure, anatomy of the base of the tongue and hypopharynx, abduction and adduction of the vocal folds, status of pharyngeal musculature and the patient's ability to handle his/her own secretions are assessed.
All bullets under CPT 92612 above, are applicable to CPT 92616.

Additional Documentation Requirements


Detailed findings of the endoscopic exam

Dysphagia Treatment

CPT 92526 Treatment of Swallowing

The Plan of Treatment should delineate goals and type of care planned which specifically addresses each problem identified in the assessment, such as:
Compensatory swallowing techniques;
Proper head and body positioning;
Amount of intake per swallow;
Means of facilitating the swallow;
Appropriate diet;
Food consistencies (texture and size);
Feeding techniques and need for self-help eating/feeding devices;
Patient caregiver training in feeding and swallowing techniques;
Facilitation of more normal tone or oral facilitation techniques;
Oromotor and neuromuscular facilitation exercises to improve oromotor control;
Training in laryngeal and vocal cord adduction exercises;
Oral sensitivity training

For oralpharyngeal or esophageal (upper one-third) phase of swallowing, documentation should include one or more of the following:

History of aspiration problems, suspected aspiration, or definite risk of aspiration;
Presence of oral motor disorder;
Impaired salivary gland performance and/or presence of local structural lesion in the pharynx resulting in marked oropharyngeal swallowing difficulties;
Dyscoordination, sensation loss, postural difficulties, or other neuromotor disturbances affecting oropharyngeal abilities necessary to close the buccal cavity and/or bite, chew, suck, shape, and squeeze the food bolus into the upper esophagus, while protecting the airway;
Post-surgical reaction with specific signs, symptoms and concerns;
Documented significant weight loss directly related to reduced oral intake as a consequence of dysphagia; and
Existence of other conditions such as the presence of tracheotomy or endotracheal tubes ventilation management, nasogastric feeding tube, reduced or inadequate laryngeal elevation, labial closure, velopharyngeal closure, or pharyngeal peristalsis and cricopharyngeal dysfunction.

For esophageal (lower two thirds) phase of swallowing, documentation should consider the following:

Esophageal dysphagia (lower two thirds of the esophagus) is regarded as 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 these patients will experience esophageal reflux or regurgitation if they lie down too soon after meals.
Inefficient functioning of the esophagus during the esophageal phase of swallowing is a common problem in the geriatric patient. Swallowing disorders occurring only in the lower two thirds of the esophageal stage of the swallow have not generally been shown to be amenable to swallowing therapy techniques and should not be submitted. An exception might be made when discomfort from reflux results in food refusal. A therapeutic feeding program in conjunction with medical management may be indicated and could constitute reasonable and necessary care. You may submit for payment a reasonable and necessary assessment of function, prior to a conclusion that difficulties exist in the lower two thirds of the esophageal phase, even when the assessment determines that skilled intervention is not appropriate.

Routine periodic progress reports are considered part of the on-going treatment sessions and are not reimbursable.
CPT 92508 Group Dysphagia Therapy

Group therapy coverage for dysphagia is covered using CPT 92508 and can be covered if the following criteria are met:
Rendered under an individualized plan of care;
Has less than five group members;
Does not represent the entire plan of treatment;
Requires the skills of a licensed therapist
Promotes independent swallowing

Additional Documentation Requirements

Documentation of the specific skilled treatments used in the group and how they relate to the Plan of Care
Documentation of number of members in group
Limitations
The patient's attending physician/NPP has established a diagnosis of dysphagia after a proper medical evaluation and/or in consultation with treating therapist.
Noncovered services include:
Screening assessments
Nondiagnostic/non therapeutic routine, repetitive observation or cueing services;
Procedures which are repetitive and/or that reinforce previously learned material which the beneficiary, staff or family may be instructed to repeat;
Procedures which can be safely and effectively carried out with the beneficiary by any non-professional (family or restorative aid) after instruction is completed;
Procedures performed on patients with chronic progressive diseases (e.g., Parkinson's disease, Huntington's disease, Wilson's disease, Multiple Sclerosis or Alzheimer's disease) without documentation to support short-term assistance teaching or instruction which would require the skills of the therapist for a maintenance program. The establishing, designing and instruction of a maintenance program is not covered if the patient would not benefit from it or refuses to participate.
E-stim as a sole modality is noncovered. However, when used during dysphagia treatment (CPT 92526) along with other reasonable and necessary services, it may be performed. It should not be billed as unattended e-stim (HCPCS G0283).

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.
999x Not Applicable

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the 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.

N/A



ICD-10 Codes that Support Medical Necessity

ICD-10 CODE DESCRIPTION

C01 - C02.8 - Opens in a new window Malignant neoplasm of base of tongue - Malignant neoplasm of overlapping sites of tongue
C04.0 - C04.8 - Opens in a new window Malignant neoplasm of anterior floor of mouth - Malignant neoplasm of overlapping sites of floor of mouth
C05.0 - C05.1 - Opens in a new window Malignant neoplasm of hard palate - Malignant neoplasm of soft palate
C15.3 Malignant neoplasm of upper third of esophagus
C32.0 - C32.9 - Opens in a new window Malignant neoplasm of glottis - Malignant neoplasm of larynx, unspecified
E01.0 Iodine-deficiency related diffuse (endemic) goiter
E01.2 Iodine-deficiency related (endemic) goiter, unspecified
F44.4 Conversion disorder with motor symptom or deficit
I69.091 Dysphagia following nontraumatic subarachnoid hemorrhage
I69.191 Dysphagia following nontraumatic intracerebral hemorrhage
I69.291 Dysphagia following other nontraumatic intracranial hemorrhage
I69.391 Dysphagia following cerebral infarction
I69.891 Dysphagia following other cerebrovascular disease
I69.991 Dysphagia following unspecified cerebrovascular disease
J38.00 - J38.02 - Opens in a new window Paralysis of vocal cords and larynx, unspecified - Paralysis of vocal cords and larynx, bilateral
J69.0 Pneumonitis due to inhalation of food and vomit
K21.9 - K22.0 - Opens in a new window Gastro-esophageal reflux disease without esophagitis - Achalasia of cardia
K22.2 Esophageal obstruction
K22.4 - K22.5 - Opens in a new window Dyskinesia of esophagus - Diverticulum of esophagus, acquired
K22.70 - K22.719 - Opens in a new window Barrett's esophagus without dysplasia - Barrett's esophagus with dysplasia, unspecified
K94.30 - K94.33 - Opens in a new window Esophagostomy complications, unspecified - Esophagostomy malfunction
R13.0 Aphagia
R13.11 - R13.14 - Opens in a new window Dysphagia, oral phase - Dysphagia, pharyngoesophageal phase
R63.3 Feeding difficulties
Z93.0 Tracheostomy status
Z96.3 Presence of artificial larynx

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