Modified Barium Swallow-HTML

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Contractor Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LCD Database ID Number

L776

LCD Title

Modified Barium Swallow

Contractor's Determination Number

00-01-R8

AMA/CPT and ADA/CPT Copyright Statement

CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply. CDT-4 codes and descriptions are Ó 2004 American Dental Association. All rights reserved.

CMS National Coverage Policy

Establishment of national policy supersedes all previous contractor policy statements, including Local Medical Policy coverage guidelines
Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

Oversight Region

Region III

CMS Consortium

Northeast

DMERC Region LCD Covers

N/A

Original Determination Effective Date

03/13/2000

Revision Effective Date

R8 05/20/2005

R7 04/29/2005

R6 09/01/2004

R5 04/01/2004

R4 10/01/2003

R3 01/01/2003

R2 09/12/2001

R1 08/10/2001

Indications and Limitations of Coverage and/or Medical Necessity

Description

Dysphagia is difficult or impaired swallowing and most often reflects organic disease involving the esophagus, proximal stomach, gastroesophageal junction, or pharynx. Patient's complaints may include the sensation of food “sticking”, “stopping”, or “hanging up”, which is usually felt above or at the level of the abnormality. Patients with dysphagia are at risk for aspiration.

An evaluation of the patient’s swallowing mechanism may include multiple processes such as a clinical bedside evaluation of swallowing, an evaluation of oral-motor functioning, or videofluoroscopic assessment.

Modified Barium Swallow Studies by Videofluoroscopy is a modified radiographic procedure for assessment of oropharyngeal dysphagia. During the examination, patients are challenged with various amounts and consistencies of barium. The events, which occur during the swallowing process, can be observed in normal speed as well as in slow motion. The instrumentation permits visualization of specific events occurring during the swallow and provides information about bolus flow through the entire oropharynx, hypopharynx, and upper esophagus. This procedure has been noted as the “gold standard” of dysphagia assessment.

This procedure may be indicated for the evaluation of a patient with dysphagia who is at risk for aspiration.

Indications

Modified Barium Swallow may be indicated for patients with the following clinical syndromes:

Stroke or other Central Nervous system (CNS) derangement with associated impairment of speech and swallowing;
Without obvious CNS disorder, but with documented difficulty in swallowing;
Clinical history of aspiration or a history of aspiration pneumonia;
Presence of oral motor disorders with symptoms such as drooling, oral food retention, leakage of food or liquids placed in the mouth; and/or,
Lack of coordination, 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.

Limitations

This procedure (HCPCS codes 70370, 70371, 74230) will only be reimbursed when medically necessary and performed in the following locations:

Office
Inpatient hospital
Outpatient hospital
Emergency room-hospital
Comprehensive inpatient rehabilitation facility
Skilled Nursing Facility
At a Skilled Nursing Facility in a Mobile Unit (Van)

Procedures performed in or at a Skilled Nursing Facility in a Mobile Unit will be reimbursed only if performed under the direct supervision of a physician trained in the procedure.

When reporting multiple radiological tests for the same date of service, National Correct Coding Combinations should be applied.

Coverage Topics

Diagnostic Tests and X-Rays

Bill Type Codes

11X, 12X, 13X, 22X, 71X, 83X, 85X

Revenue Codes

32X, 440

CPT/HCPCS Codes

The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT book for the long description of the following codes:

70370	©	Radiologic examination, including fluoroscopy and/or magnification technique
70371	©	Complex dynamic pharyngeal and speech evaluation
74230	©	Swallowing function, with cineradiography and/or video
92611	©	Motion fluoroscopic evaluation of swallowing function by cine or video recording

Does the "CPT 30% Coding Rule" Apply?

N/A

ICD-9 Codes that Support Medical Necessity

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the claim is submitted.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid.

Covered for:

150.0-150.9		Malignant neoplasm of esophagus
235.6		Neoplasm of uncertain behavior of larynx
239.1		Neoplasm of unspecified nature, respiratory system
332.0		Paralysis agitans
332.1		Secondary Parkinsonism
333.0		Other degenerative diseases of the basal ganglia
333.2		Myoclonus
333.4		Huntington’s chorea
333.5		Other choreas
333.6		Idiopathic torsion dystonia
333.81-333.89		Fragments of torsion dystonia
333.90-333.99		Other and unspecified extrapyramidal diseases and abnormal movement disorders
335.20		Amyotrophic lateral sclerosis
341.0-341.9		Other demyelinating diseases of central nervous system
342.00-342.92		Hemiplegia and hemiparesis
436		Acute, but ill-defined, cerebrovascular disease
438.11		Speech and language deficits, aphasia
438.12		Speech and language deficits, dysphasia
438.20		Hemiplegia affecting unspecified side
438.21		Hemiplegia affecting dominant side
438.22		Hemiplegia affecting nondominant side
438.82		Other late effects of cerebrovascular disease, dysphagia
464.0		Acute laryngitis
464.00		Without mention of obstruction
464.01		With obstruction
478.30-478.34		Paralysis of vocal cords or larynx
478.6		Edema of larynx
507.0		Pneumonitis due to solids and liquids, 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
783.3		Feeding difficulties and mismanagement
787.2		Other late effect of cerebrovascular disease, dysphagia
933.1		Foreign body in larynx
934.0		Foreign body in trachea
934.1		Foreign body in main bronchus
V48.3		Mechanical and motor problems with neck and trunk

Diagnoses that Support Medical Necessity

N/A

ICD-9 Codes that DO NOT Support Medical Necessity

N/A

Diagnoses that DO NOT Support Medical Necessity

N/A

Documentation Requirements

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and available to Medicare upon request.
To report these services, use the appropriate HCPCS code.
An appropriate diagnosis code must be submitted on the claim. The patient’s medical record should indicate the signs/symptoms supporting the diagnosis and functional impairment
Document that the exact diagnosis of the swallowing disorder cannot be substantiated through oral exam and there is a question whether aspiration is occurring. The assessment and final analysis and interpretation should document a definitive diagnosis, identification of the swallowing phase(s) affected, and recommend the treatment plan.
Input and/or analysis by an individual discipline should be documented in the medical record.

Utilization Guidelines

Medicare will monitor the utilization of this service through the Medical Review process.

Sources of Information and Basis for Decision

CMS Pub. 100-02, Chapter 15, §80.4
CMS Pub. 100-8, Chapter 6,§10
Intermediary Medical Director
Medicare Part A Speech Language Pathology Consultant
Empire Medicare Services Medical Policy
Veritus Medicare Services Medical Policy

Advisory Committee 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 the appropriate specialty(ies).

Advisory Committee Meeting Date:

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period

Revision History Number

Revision History Explanation

R8	Under “Limitations”, addition of location for performance of this procedure to include a Mobile Unit at a Skilled Nursing Facility with the requirement that the procedure will only be reimbursed when performed under the direct supervision of a physician trained in the procedure.
R7	Under “Limitations”, addition of Skilled Nursing Facility as a location for performance of this procedure with the requirement that the procedure will only be reimbursed when performed under the direct supervision of a physician trained in the procedure.
R6	Converted ICD-9 code 438.2 to 5 digits: 438.20, 438.21, 438.22
R5	HCPCS 92610 included by mistake, removed. LMRP converted to LCD format. Updated
	CMS references.
R4	In the 4^th bullet, under “Indications”, changed “and” to “and/or”. Added “Responsibility” under
	“Comments”.
R3	Annual update of CPT/HCPCS codes. Codes 92525 and G0196 discontinued, with a 3-month
	grace period and addition of 92610 and 92611. CPT/HCPCS code descriptors changed
	to short descriptor.
R2	ICD-9 coverage expanded due to the addition of new code for FY 2002.(09/12/2001 Provider
	Bulletin)
R1	Addition of Level II HCPCS code, G0196 (08/10/2001 Provider Bulletin)

Does this LCD contain a “Least Costly Alternative” provision?

Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.