LCD : Barium Swallow (Video/Cine) (L1348)

LCD for Barium Swallow (Video/Cine) (L1348)

Contractor Information

Contractor Name

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number

00390

Contractor Type

LCD Information

LCD ID Number

L1348

LCD Title

Barium Swallow (Video/Cine)

Contractor's Determination Number

1348

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2007 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.

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section excludes coverage for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Primary Geographic Jurisdiction

New Jersey
Tennessee

Secondary Geographic Jurisdiction

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming

Oversight Region

Region IV

Original Determination Effective Date

For services performed on or after 10/16/1997

Original Determination Ending Date

Revision Effective Date

For services performed on or after 04/20/2006

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

Modified barium swallow studies by video fluoroscopy is used to more objectively diagnose disorders of swallowing and aspiration and aid in selecting an appropriate treatment plan.

The HCPCS codes will be reimbursed when medically necessary and performed in the following locations:

Inpatient Hospital
Inpatient Rehabilitation Hospital
Outpatient Hospital Setting
Outpatient Rehabilitation Hospital
Emergency Room Setting
CORF Facility

Coverage Topic

Diagnostic Tests and X-Rays

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.

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.

032X	Radiology diagnostic-general classification
033X	Radiology therapeutic-general classification
034X	Nuclear medicine-general classification
035X	Computed tomographic (CT) scan-general classification
040X	Other imaging services-general classification
061X	Magnetic resonance technology (MRT)-general classification

CPT/HCPCS Codes

70370	RADIOLOGIC EXAMINATION; PHARYNX OR LARYNX, INCLUDING FLUOROSCOPY AND/OR MAGNIFICATION TECHNIQUE
70371	COMPLEX DYNAMIC PHARYNGEAL AND SPEECH EVALUATION BY CINE OR VIDEO RECORDING
74230	SWALLOWING FUNCTION, WITH CINERADIOGRAPHY/VIDEORADIOGRAPHY

ICD-9 Codes that Support Medical Necessity

148.0 - 148.9	MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX - MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE
150.0 - 150.9	MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE
438.82	DYSPHAGIA CEREBROVASCULAR DISEASE
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
710.3	DERMATOMYOSITIS
710.4	POLYMYOSITIS
783.3	FEEDING DIFFICULTIES AND MISMANAGEMENT
787.20	DYSPHAGIA, UNSPECIFIED
787.21	DYSPHAGIA, ORAL PHASE
787.22	DYSPHAGIA, OROPHARYNGEAL PHASE
787.23	DYSPHAGIA, PHARYNGEAL PHASE
787.24	DYSPHAGIA, PHARYNGOESOPHAGEAL PHASE
787.29	OTHER DYSPHAGIA

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentation Requirements

The medical necessity for the test must be established in the patient’s medical record. This test must be ordered by the beneficiary’s physician.

Documentation must establish that oral/pharyngeal disorders are suspected, that an exact diagnosis cannot be substantiated through oral exam and that there is question as to whether aspiration is occurring.

Appendices

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions

Utilization Guidelines

Sources of Information and Basis for Decision

Carrier policy

Medicare Technical Advisory Committee

CMS Pub 100-2, 15 §80.4.1-§80.4.4, Pub 100-4, 13 §90

Medicare Intermediary Manual, Section 3910

Advisory Committee Meeting Notes

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from various specialties.

Start Date of Comment Period

08/01/1997

End Date of Comment Period

Start Date of Notice Period

09/15/1997

Revision History Number

1348a

Revision History Explanation

07/29/2004 Crosswalked references to Online Manuals

07/24/2002 Formatted

This LCD was converted from an LMRP on 12/6/2005
ICD9 code 438.82 was added to Group 1 on 04/20/2006

09/03/2007 - This policy was updated by the ICD-9 2007-2008 Annual Update.

10/04/2007 - Frequently Asked Questions restored to Appendices.