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).




Exceptions for Evaluation Services

Evaluation. The CMS will except therapy evaluations from caps after the therapy caps are reached when evaluation is necessary, e.g., to determine if the current status of the beneficiary requires therapy services. For example, the following CPT codes for evaluation procedures may be appropriate:

92521, 92522 , 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004. These codes will continue to be reported as outpatient therapy procedures as listed in the Annual Therapy Update for the current year at: http://www.cms.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage. They are not diagnostic tests. Definitions of evaluations and documentation are found in Pub. 100-02, sections 220 and 230.

Other Services. There are a number of sources that suggest the amount of certain services that may be typical, either per service, per episode, per condition, or per discipline. For example, see the CSC - Therapy Cap Report, 3/21/2008, and CSC – Therapy Edits Tables 4/14/2008 at www.cms.hhs.gov/TherapyServices (Studies and Reports), or more recent utilization reports. Professional literature and guidelines from professional associations also provide a basis on which to estimate whether the type, frequency, and intensity of services are appropriate to an individual. Clinicians and contractors should utilize available evidence related to the patient’s condition to justify provision of medically necessary services to individual beneficiaries, especially when they exceed caps. Contractors shall not limit medically necessary services that are justified by scientific research applicable to the beneficiary. Neither contractors nor clinicians shall utilize professional literature and scientific reports to justify payment for continued services after an individual’s goals have been met earlier than is typical. Conversely, professional literature and scientific reports shall not be used as justification to deny payment to patients whose needs are greater than is typical or when the patient’s condition is not represented by the literature.



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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