Swallowing Studies for Dysphagia

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 CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. 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. CPT is a registered trademark of the American Medical Association. 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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 Experimental42 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 DefinedCMS 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 PathologyCMS 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 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

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)