Contractor Information
Contractor Name:
Highmark Medicare Services
Contractor Number:
12102, 12202, 12302
Contractor Type:
MAC Part A & B
LCD Information
LCD Database ID Number
L27537
LCD Title
Speech-Language Pathology (SLP) Services: Dysphagia; Includes VitalStim® Therapy
Contractor’s Determination Number
L27537
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) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
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 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
CMS Manual System, IOM Pub. 100-02, Medicare Benefit Policy Manual; IOM Pub. 100-03, Medicare National Coverage Determinations Manual; and IOM Pub 100-04, Medicare Claims Processing Manual.
CMS Publication, IOM 100-02, Medicare Benefit Policy Manual, Transmittal No 88, Change Request #5921, May 7, 2008, describes Therapy Personnel Qualifications and Policies Effective January 1, 2008.
Primary Geographic Jurisdiction
Maryland, District of Columbia, Delaware
Oversight Region
Central Office
Original Determination Effective Date
For services performed on or after 07/11/2008
Original Determination Ending Date
N/A
Revision Effective Date
For services performed on or after N/A
Revision Ending Date
N/A
Indications and Limitations of Coverage and/or Medical Necessity
Compliance with the provisions in this policy may be monitored and addressed through data analysis and medical review audits.
Note: This LCD addresses treatment of swallowing dysfunction and/or oral function for feeding. For the treatment of associated problems, for example, feeding difficulty due to paralysis from a stroke, please see LCD L27513, Physical Medicine and Rehabilitation Services. Please see LCD L27531, Speech-Language Pathology (SLP) Services: Communication Disorders, for these services.
Dysphagia, or difficulty in swallowing, can cause 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 death. Patients' symptoms may include the sensation of food "sticking", "stopping", or "hanging up", which is usually felt above or at the level of the abnormality. Dysphagia may involve the oral cavity, pharynx, esophagus, gastroesophageal junction, or proximal stomach. It may occur due to complex neurological and / or structural impairments including head and neck trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, dementias and encephalopathies, for example.
Speech-Language Pathology Services for the Treatment of Dysphagia are addressed in the CMS NCD 170.3. Please see the following CMS Manuals for guidance regarding the evaluation and treatment of dysphagia:
Medicare Benefit Policy Manual, IOM 100-02, Chapter 15, Sections 220 and 230.3; Medicare National Coverage Determinations Manual, IOM 100-03, Chapter 1, Section 170.3; and Medicare Claims Processing Manual, IOM 100-04.
http://www.cms.hhs.gov/Manuals/IOM
You may also visit the CMS Coverage Center at:
http://www.cms.hhs.gov/center/coverage.asp
Note: No specific ICD-9-CM codes are provided here; the provider is responsible to select codes carried out to the highest level of specificity to characterize the problem and support the medical necessity of the services rendered.
Coverage Limitations
VitalStim® is a type of neuromuscular electrical stimulation therapy for the treatment of dysphagia, which uses small electrical currents to stimulate the muscles responsible for swallowing. VitalStim® is used in conjunction with traditional dysphagia treatment of oromotor exercises, and swallowing strategies.
Based upon review of the scientific and clinical literature, the clinical efficacy and clinical utility of this service remains unproven. Recent studies with the use of this surface electrical stimulation treatment show a lowering of the hyoid bone during swallowing, which may actually be harmful to the patient. Because the code for dysphagia treatment is a comprehensive code which includes all treatment approaches, payment may be made for other medically necessary dysphagia treatments.
VitalStim® therapy will not be covered by Medicare and treatment will be deemed not reasonable and necessary in the treatment of patients with dysphagia.
Coverage Topic
Physical, Occupational, and Speech Therapy
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.
11x | Hospital-inpatient (including Part A) |
12x | Hospital-inpatient or home health visits (Part B only) |
13x | Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) |
18x | Hospital-swing beds |
21x | SNF-inpatient, Part A |
22x | SNF-inpatient or home health visits (Part B only) |
23x | SNF-outpatient (HHA-A also) |
74x | Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97) |
75x | Clinic-CORF |
83x | Special facility or ASC surgery-ambulatory surgical center (Discontinued for Hospitals Subject to Outpatient PPS; hospitals must use 13X for ASC claims submitted for OPPS payment -- eff. 7/00) |
85x | Special facility or ASC surgery-rural primary care hospital (eff 10/94) |
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.
043X | Occupational therapy-general classification |
044X | Speech language pathology-general classification |
CPT/HCPCS Codes
Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.
92526 | TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION FOR FEEDING |
ICD-9 Codes that Support Medical Necessity
It is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.
|
XX000 |
NOT APPLICABLE |
Diagnoses that Support Medical Necessity
N/A
ICD-9 Codes that DO NOT Support Medical Necessity
N/A
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Conditions that are not listed in the “ICD-9-CM Codes that Support Medical Necessity” section of this policy.
General Information
Documentation Requirements
- All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
- The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Sources of Information and Basis for Decision
Ali,GN, et al. Predictors of outcome following cricopharyngeal disruptions for pharyngeal dsyphagia. Dysphagia 1997; 12: 133-139.
Burnett TA, Mann EA, Stoklosa JB, and Ludlow CL. Self-Triggered Functional Electrical Stimulation During Swallowing. J Neurophysiol. 2005; 94: 4011-4018.
Freed, et al. Electrical Stimulation for Swallowing Disorders Caused by Stroke. Respiratory Care. 2001; 46 (5): 466-74.
Hamdy S, et al. Recovery of Swallowing After Dysphagic Stroke Relates to Functional Reorganization in the Intact Motor Cortex. Gastroenterology 1998;115: 1104-1112.
Humbert IA, Poletto CJ, et al. The Effect of Surface Electrical Stimulation on Hyo-Laryngeal Movement in Normal Individuals at Rest and During Swallowing. J Appl Physiol. 2006; 101: 1657-1663.
Kanaya F, et al. Effect of Electrostimulation on Denervated Muscle. Clinical Orthopaedics and Related Research. 1992; 282:296-301.
Leelemanit, et al. Synchronized Electrical Stimulation in Treating Pharyngeal Dysphagia. Laryngocope 112 (12): 2204-10.
Logemann J. Approaches to management of disordered swallowing. Bailliere's Clinical Gastroenterology.1191; 5:269-280.
Ludlow CL, Humbert I, et al. Effects of Surface Electrical Stimulation Both at Rest and During Swallowing in Chronic Pharyngeal Dysphagia. Dysphagia. 2007; 22(1): 1-10.
Park C, et al. A Pilot Exploratory Study of Oral Electrical Stimulation on Swallow Function following Stroke: An Innovative Technique. Dysphagia 1997;12: 161-166.
Yokoyama M., et al. Role of Laryngeal Movement and Effect of Aging on Swallowing Pressure in the Pharynx and Upper Esophageal Sphincter. Laryngoscope 110 (3); 434-439.
Contractor Medical Directors New Technology Medicine/Surgery Clinical Workgroup
Other Contractors’ policies
Highmark Medicare Services Contractor Medical Directors
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 Otolaryngology, Radiology, and Physiatry.
CAC/IAC Distribution: 04/01/2008
Start Date of Comment Period
End Date of Comment Period:
05/15/2008
Start Date of Notice Period
05/23/2008
Revision History
Revision History Number
L27537
Revision History Explanation
| Date | Policy # | Description |
|---|---|---|
05/23/2008 |
L27537 |
Original LCD posted for notice. LCD to become effective 07/11/2008 for Maryland Part B, DCMA Part B and Delaware Part B. |
04/01/2008 |
Draft J12-D51 |
Original LCD posted for comment. |
Last Reviewed On
05/22/2008