| LCD ID Number back
to top |
| L20626 |
| |
| LCD Title back
to top |
| Dysphagia Services |
| |
| Contractor's Determination
Number back
to top |
| 20626 |
| |
| AMA CPT / ADA CDT Copyright
Statement back
to top |
| CPT codes, descriptions and other data
only are copyright 2005 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 back
to top |
Language quoted from CMS National Coverage
Determinations (NCDs) and coverage provisions in interpretive
manuals is italicized throughout the policy. NCDs and coverage
provisions in interpretive manuals are not subject to the LCD Review
Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart
D]).
Unless otherwise specified, italicized text
represents quotation from one or more of the following CMS
sources:
Section 1833(e) of Title XVIII of the Social
Security Act prohibits Medicare payment for any claim which lacks
the necessary information to process the claim.
Section
1835(a)(2)(D) of Title XVIII of the Social Security Act lists
requirements for certification and recertification of outpatient
speech pathology services.
Section 1862(a)(1)(A) of Title
XVIII of the Social Security Act excludes expenses incurred for
items or services which are not reasonable and necessary for the
diagnosis or treatment of illness or injury or to improve the
functioning of a malformed body member.
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 chapter 8, section 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, chapter 12, section 40.4
discusses coverage issues related to SLP services provided in
CORFs.
CMS Pub. 100-2, Medicare Benefit Policy Manual
chapter 15, section 80.4.4 describes coverage of portable x-ray
services.
CMS Pub. 100-2 Medicare Benefit Policy
Manual, chapter 15, section 220.1 describes therapy services
furnished under arrangements with providers and clinics.
CMS
Pub. 100-2 Medicare Benefit Policy Manual, chapter 15,
section 230.3 outlines covered speech pathology services.
CMS
Pub. 100-2 Medicare Benefit Policy Manual, chapter 15,
section 220.3.1 describes physician certification/ recertification
requirements.
CMS Publication 100-3 Medicare National
Coverage Determinations Manual, chapter 1, section 170.3
describes speech pathology services for the treatment of
dysphagia. |
| |
| Primary Geographic
Jurisdiction back
to top |
New Jersey
Tennessee
|
| |
| Secondary Geographic
Jurisdiction back
to top |
Alaska
Alabama
Arkansas
Arizona
California -
Entire
State
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
- Entire State
Mississippi
North Carolina
North
Dakota
Nebraska
New Mexico
Nevada
New York - Entire
State
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode
Island
South
Carolina
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West
Virginia
Wyoming
|
| |
| Oversight
Region back
to top |
| Region IV |
| |
| CMS Consortium back
to top |
| Southern |
| |
| Original Determination
Effective Date back
to top |
| For services performed on or after
09/30/2005 |
| |
| Original Determination
Ending Date back
to top |
| |
| |
| Revision Effective
Date back
to top |
| |
| |
| Revision Ending
Date back
to top |
| |
| |
| Indications and Limitations
of Coverage and/or Medical Necessity back
to top |
INDICATIONS AND
LIMITATIONS
Speech-language pathologists,
occupational therapists and physical therapists may be involved with
dysphagia services to the extent that their training and scope of
practice allows.
Dysphagia or difficulty in swallowing is a
disorder that may be due to various neurological, structural and
cognitive deficits and deconditioning. It may be the result of head
and neck trauma, cerebrovascular accident, neuromuscular
degenerative diseases, head and neck cancer, and encephalopathies.
Dysphagia most often reflects problems involving the oral cavity,
pharynx, esophagus, gastroesophageal junction, or proximal stomach.
Patients with dysphagia can be at risk for aspiration in which
solids or liquids to enter the airway, resulting in coughing,
choking, aspiration, or inadequate nutrition and hydration with
resultant weight loss, failure to thrive, pneumonia, and possibly
death.
An evaluation of the patient’s swallowing mechanism
may include a clinical bedside evaluation of swallowing, evaluation
of oral-motor functioning, and/or instrumental assessment.
Dysphagia Criteria for Diagnosis
In order
for additional evaluation and/or therapy to be indicated, at least
one of the following conditions must be present:
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.
Signs or symptoms of Oral, Pharyngeal, or Upper
Esophageal Dysfunction indicate a need for evaluation and possible
treatment:
- Presence of oral motor disorders such as drooling, oral food
retention, leakage of food or liquids placed into the
mouth.
- Impaired salivary gland performance and/or presence of local
structural lesions in the pharynx resulting in marked
oropharyngeal swallowing difficulties.
- Incoordination, sensation loss, (postural difficulties) or
other neuromotor disturbances affecting oropharyngeal abilities
necessary to close the buccal cavity and/or bite, chew, suck,
shape and squeeze the food bolus into the upper esophagus while
protecting the airway.
- Post-surgical sequellae affecting ability to adequately use
oropharyngeal structures used in swallowing.
- Significant weight loss directly related to non-oral
nutritional intake (g-tube feeding) and reaction to textures and
consistencies.
- 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.
Signs
and symptoms of middle or lower esophageal dysfunction may indicate
a need for further evaluation and recommendations but do not
indicate a need for therapy:
- If peristalsis is inefficient, the patient will have
difficulty in passing food from the esophagus to the
stomach.
- Patients may complain of food getting stuck or of having more
difficulty swallowing solids than liquids.
- Some patients may experience esophageal reflux or
regurgitation if they lie down too soon after
meals.
Consultation to Establish Safety
or Maintenance Program
Patients with progressive
disorders, such as Parkinson's disease, Huntington's disease,
Wilson's disease, multiple sclerosis, or Alzheimer's disease and
related dementias, do not typically show improvement in swallowing
function, but will often be helped through short-term
assistance/instruction in positioning, diet, feeding modifications,
and in the use of self-help devices. Short-term assistance/teaching
to establish a safe and effective maintenance dysphagia program may
be medically necessary if a similar program has not been previously
developed for that patient.
Although the usual goal of
dysphagia therapy is to improve a patient's swallowing function, it
also may be important merely to establish 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.
Chronic diseases such as
cerebral palsy, status post-head trauma or stroke (old) similarly
may require an evaluation of swallowing function with short-term
intervention to maximize either safety or swallowing effectiveness
even though the static condition is not amenable to actual therapy.
Medical necessity in all of these instances is based on the loss of
function (and its consequences) as well as the potential for change;
both must be clearly assessed in the medical record for medical
necessity to be met.
The development of a maintenance program
may be covered as reasonable and necessary if it also qualifies as
skilled care. The development of a maintenance program could also be
considered to be a professional consultation as it includes the
following:
- Evaluation
- Treatment Plan(s)
- Staff, patient and
caregiver training as indicated
- Re-evaluation (if indicated
by the occurrence of specific signs and
symptoms.)
Skilled Level of
Care
Dysphagia therapy services are only medically when
skilled services are provided. The clinical record should clearly
support the need for skilled services such as skilled observation
for diagnostic purposes, selection of appropriate treatment
regimens, and dietary modification consistent with the needs of the
patient. Services that are routine, repetitive, within either the
general scope of non-skilled custodial or skilled nursing care, or
easily related to simple cues will not be considered to be medically
necessary for the unique skills of a Speech Language Pathologist or
related therapist.
Clinical Bedside Assessment
(CPT code 92610)
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’s clinical assessment must document history,
appropriate diagnosis, current eating status, and pertinent clinical
observations including a nutritional assessment, behavioral and
cognitive assessment, environmental assessment including
positioning, behavioral and cognitive assessment, an assessment of
observed 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.
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.
The ordering
physician needs to have actually examined and evaluated the
patient's medical condition in order to establish the need for a
dysphagia evaluation. Documentation by the evaluating physician must
support the need for a dysphagia workup prior to the initiation of
therapy. It is not acceptable for the physician to simply sign a
form ordering swallowing therapy at the request of the therapist or
nursing staff without the physician having actually performed an
examination. Patients needing dysphagia therapy require an
appropriate evaluation and workup in order to establish the
appropriate therapy required.
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.
Instrumental Assessments Used to Study
Swallowing
Instrumental assessments used for diagnostic
purposes, e.g., fiberoptic endoscopic examination, should be
performed and interpreted by an otolaryngologist or other physician
with training in these procedures, or may be performed by SLPs under
the direct supervision of an otolaryngologist or other physician
with training in these procedures. 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. Care should be exercised to
perform such an examination in a setting that assures patient
safety. Because of potential adverse reactions to these
procedures, direct supervision by a physician, that is, the
physician being present within the same office suite, available and
able to intervene, must be met and documented. In a hospital
setting, the physician supervision requirement is presumed to be met
and need not be documented.
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;
- timing and duration of the oral and
pharyngeal stages of swallowing.
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.
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.)
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 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 if that
dysfunction has been unequivocally identified by clinical
means.
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 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 and prior to initiating any therapy.
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.
Instrumental
Assessments:
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 clearance in the upright position,
sensation and muscle strength may be measured directly or inferred.
The videofluoroscopic swallowing study is a collaborative study that
can be performed by the speech-language pathologist and
radiologist.
The performance of a videofluoroscopic
assessment is only medically necessary when the disorder cannot be
substantiated through oral examination. There must be a question as
to whether there is a pharyngeal deficit, aspiration is actually
occurring, or the patient is at high risk for aspiration. The MBS
must be conducted and interpreted by a radiologist with the
assistance and input from the physician and/or speech
pathologist.
Endoscopic Assessment of Swallowing
Functions (CPT code 92612 if cine or video recording is used,
92700 without cine or video recording)
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.
The patient
may be evaluated at the bedside location. FEES may be performed by a
physician or speech-language pathologist with direct physician
supervision and may be a collaborative evaluation involving both
disciplines.
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.
Fiberoptic Endoscopic Evaluation of
Swallowing with Sensory Testing (CPT code 92616 if cine or video
recording is used, 92700 without cine or video recording)
Fiberoptic Endoscopic Evaluation of Swallowing with Sensory
Testing (FEESST) is a modification of FEES, with the addition of
specialized equipment that quantifies the sensory threshold in the
larynx. FEESST may be performed by a physician, or speech-language
pathologist with direct physician supervision. This may be a
collaborative evaluation involving both disciplines.
The
special equipment for FEESST includes a sensory stimulator that
allows quantification of stimuli, a television monitor, a video
printer, and a videocassette recorder. Velopharyngeal closure,
anatomy of the base of the tongue and hypopharynx, abduction and
adduction of the vocal folds, status of pharyngeal musculature and
the patient’s ability to handle his/her own secretions are
assessed.
The sensory evaluation is completed by delivering
pulses of air at sequential pressures to elicit the laryngeal
adductor reflex. A sensory threshold is thus established. Motor
evaluation is completed by giving various food items with different
consistencies while factors such as oral transit time, inhibition of
swallowing, laryngeal elevation, spillage, residue, condition of
swallow, laryngeal closure, reflux, aspiration, and ability to clear
residue are monitored. The entire procedure may be done at bedside.
The use of anesthesia may interfere with the sensory test and is
usually not indicated.
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.
Indications for
Instrumental Assessments:
Instrumental assessment of
swallowing may be indicated for the evaluation of a patient with
dysphagia who has a pharyngeal dysfunction or who is at risk for
aspiration.
Examples of 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 ablation 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;
- Patients with head or
neck (throat) injury.
Instrumental assessment of
swallowing data should be used in the clinical decisions whether to
place feeding gastrostomy tubes, in the everyday dietary management
of the impaired patient, and to order/plan/evaluate appropriate
therapy programs.
Instrumental assessment of swallowing by
videofluoroscopy and endoscopic studies are considered medically
necessary only when performed in the following places of
service:
- Inpatient hospital
- Outpatient hospital
-
Comprehensive outpatient rehabilitation facility (with direct
physician supervision)
- Skilled Nursing Facility (with direct
physician supervision)
Dysphagia Treatment
(CPT Code 92526)
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.
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.
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.
Although 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 been
shown to be amenable to swallowing therapy techniques. 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.
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.
The duration of therapy for
swallowing disorders may vary from patient to patient. Typically the
establishment of a maintenance program, including instruction of the
patient and caregiver, 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.
More than four sessions to establish a maintenance program will
typically be a signal to the Intermediary to request records, which
would be expected to clearly document the unique circumstances that
prevented the establishment of the program in the anticipated
timeframe. The occurrence of abbreviated sessions not clearly
required by patient limitations, undue repetition, and a lack of
clinical notes documenting the accomplishments of each individual
session will result in a determination that some or all of the
sessions were not medically necessary.
The performance of a
therapy program also varies considerably. More than six to nine
sessions to progress to a point where repetition and unskilled
supervision will maintain the patient will typically be a signal to
the Intermediary to request records, which would be expected to
clearly document the unique circumstances that required the ongoing
services. The occurrence of abbreviated sessions not clearly
required by patient limitations, undue repetition in the absence of
evolving instruction or other nonskilled services, and a lack of
clinical notes documenting the accomplishments of each individual
session will result in a determination that some or all of the
sessions were not medically necessary. More than twelve sessions
will not be considered to be medically necessary although this
determination will not be binding on appeal if a truly unique
clinical situation can be documented in which all the sessions are
unambiguously shown to be medically necessary.
|
| |
| Coverage Topic back
to top |
Physical, Occupational, and Speech
Therapy
| |