Local Coverage Determination (LCD)

Swallowing Studies for Dysphagia

L33449

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33449
Original ICD-9 LCD ID
Not Applicable
LCD Title
Swallowing Studies for Dysphagia
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 11/14/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

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Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be 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, §1862(a)(1)(D) Investigational or Experimental

42 Code of Federal Regulations §410.32(a) Diagnostic tests must be ordered by the physician treating the beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific problem.

42 Code of Federal Regulations §411.15(k)(1) Services that are not reasonable necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are excluded from coverage.

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 6, §20.4.1 Diagnostic Services Defined

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §§220-220.4 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §230.3 Practice of Speech-Language Pathology

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 3, §170.3 Speech-Language Pathology Services for the Treatment of Dysphagia

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

This LCD describes Medicare coverage for instrumental assessment of swallowing. Instrumental assessment of swallowing is indicated for either the evaluation of a patient with dysphagia who has a pharyngeal dysfunction or who is at risk for aspiration. Such study is indicated after clinical (noninstrumental) examination identifies an issue that cannot be resolved without further assessment.


The 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-reclining position and given various quantities and textures of food and/or liquids mixed with a contrast material. The 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 a speech-language pathologist and a radiologist.

Among the important clinical syndromes that contribute to the presentation of dysphagia and 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 neuromuscular diseases and rheumatologic diseases known to cause dysphagia.
  • Patients with a clinical history of aspiration or a history of aspiration pneumonia.
  • Patients with head or neck (throat) injury, including peripheral nerve injury from any cause.

Concerns have been expressed that the use of such services in a mobile setting lacks evidence of medical effectiveness. Questions of patient safety have yet to be resolved for these types of procedures to be performed in a Skilled Nursing Facility (SNF), nursing home or home environment, thus requiring physician presence during the procedure in such settings.

This procedure will be reimbursed only when medically necessary and performed in the following places of service:

• Office (11)
• Off Campus-Outpatient Hospital (19)
• Inpatient Hospital (21)
• On Campus-Outpatient Hospital (22)
• Emergency Room Hospital (23)
• Comprehensive Inpatient Rehabilitation Facility (61)
• Comprehensive Outpatient Rehabilitation Facility (62)

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to the A/B MAC upon request.

Sources of Information
  • Contractor Medical Director (CMD) Fiscal Intermediary Clinical Workgroup "Dysphagia" Template Policy.
  • PSC Workgroup: "Medical Review of Dysphagia Services – Part B" Template Policy.
Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
11/14/2019 R10

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Swallowing Studies for Dysphagia A56621 article.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
06/27/2019 R9

All coding and verbiage located in the Coding Information section has been moved into the related Billing and Coding: Swallowing Studies for Dysphagia A56621 article and removed from the LCD. 

All verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section and the Associated Information section has been removed and is included in the related Billing and Coding: Swallowing Studies for Dysphagia A56621 article. Moved cited workgroup sources from Bibliography to Sources of Information. Formatting, punctuation and typographical errors were corrected throughout the LCD. 

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
10/01/2018 R8

Under ICD-10 Codes that Support Medical Necessity Group 2: Codes ICD-10 codes I63.8 and I71.0 have been deleted. Under ICD-10 Codes that Support Medical Necessity Group 2: Codes ICD-10 codes I63.81, I63.89, I67.850, G71.00, G71.01, G71.02, G71.09 have been added. Under ICD-10 Codes that Support Medical Necessity Group 2: Codes ICD-10 codes I63.333 and I63.343 have been revised. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2018.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Revisions Due To ICD-10-CM Code Changes
02/26/2018 R7 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
10/01/2017 R6

Under ICD-10 Codes that Support Medical Necessity Group 2: Codes added ICD-10 codes G12.23 and G12.24. The code description was revised for ICD-10 codes I63.323, I63.333, I63.513, I63.523, I63.533, M33.00, M33.01, M33.02, M33.09, M33.10, M33.11, M33.12 and M33.19. These revisions are due to the 2017 Annual ICD-10 Updates.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. 


 

 

  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
03/16/2017 R5 Under CMS National Coverage Policy grammatical correction to remove the “s” from “Internet-Only Manuals” listed. Added verbiage to 42 Code of Federal Register 410.32(a) to read Diagnostic tests must be ordered by the physician treating the beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific problem. Also added verbiage to 42 Code of Federal Register 411.15(k)(1) to now read “…are excluded from coverage”. Under Coverage Indications, Limitations and/or Medical Necessity- Remove sentence as redundant, “Instrumental assessment of swallowing is indicated for either the evaluation of a patient with dysphagia who has a pharyngeal dysfunction or who is at risk for aspiration.” Under Associated Information – Documentation Requirements- Grammatical error correction, to remove “the” from “Documentation supporting “the” medical necessity should be legible, maintained in the patient’s medical record and made available to the A/B MAC upon request.
  • Provider Education/Guidance
  • Typographical Error
10/01/2016 R4 Under ICD-10 Codes that Support Medical Necessity Group 1: Paragraph deleted Report dysphagia with the primary diagnosis of I69.091, I69.191, I69.291, I69.391, I69.891, I69.991, J69.0, R13.0,* R13.10-R13.14*, R13.19* or T17.XXXX codes listed in Group 1. Under ICD-10 Codes That Support Medical Necessity Group 2: Codes added ICD-10 codes C49.A1, I63.013, I63.033, I63.113, I63.133, I63.213, I63.233, I63.313, I63.323, I63.333, I63.343, I63.413, I63.423, I63.433, I63.443, I63.513, I63.523, I63.533 and I63.543. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/1/16.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
07/29/2016 R3 Under Coverage Indications, Limitations and/or Medical Necessity in the last paragraph added a new Place of Service (POS) code 19 “Off Campus-Outpatient Hospital (19)” and revised the verbiage to POS code 22 “Outpatient Hospital (22)” to read “On Campus-Outpatient Hospital (22)”.
  • Reconsideration Request
02/11/2016 R2 Under CMS National Coverage Policy punctuation was corrected. The spelling of “treating” was corrected and “Ordering” was deleted from the descriptive verbiage for 42 CFR §410.32 (a). The verbiage “Part 3” was deleted from the following citation: CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §230.3 Practice of Speech-Language Pathology and added to the cited NCD. Under Coverage Indications, Limitations and/or Medical Necessity deleted “videofluoroscopic” in the first sentence of the second paragraph as it was redundant. In the sixth paragraph added “…places of service.” Under ICD-10 Codes That Support Medical Necessity deleted the Note. In the second paragraph revised “and” to read “or” and deleted the “or” after J69.0 and added a comma. Asterisks were added for Group 1 ICD-10 codes R13.0, R13.10, R13.11, R13.12, R13.13, R13.14, and R13.19 as these are primary codes that require an additional secondary (dual) diagnosis from Group 2 to be billed. Under ICD-10 Codes That Support Medical Necessity-Group 1 Paragraph deleted the sentence that reads “At least one…” and moved this to the Group 1: Medical Necessity ICD-10 Codes Asterisk Explanation. Under Associated Information-Documentation Requirements added “the” to the sentence. Under Sources of Information and Basis for Decision deleted the other contractor LCDs cited as this information was archived.
  • Provider Education/Guidance
  • Typographical Error
  • Other
10/01/2015 R1 Under ICD-10 Codes that Support Medical Necessity Group 2: Codes, added ICD-10 code R05.
  • Provider Education/Guidance
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56621 - Billing and Coding: Swallowing Studies for Dysphagia
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
11/09/2019 11/14/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Swallowing Studies for Dysphagia
  • Swallowing Studies
  • Dysphagia

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