# Modified Barium Swallow



## TracieHewitt

We are billing 74230 - Modified Barium Swallow.  The Report is as follows:

HISTORY:  Dysphagia.  Possible aspiration.

In the lateral projection with fluoroscopic observation and DVD recording the patient ingested barium pudding, thick and thin liquid barium, barium coated cracker and water.  No aspiration. No cough. No significant vallecula or pyriform sinus pooling.  

Extensive degenerative changes spine.

Impression:

No aspiration identified.  No cough.  Negative study


My question is....This is a Medicare patient and we have our primary dx of 787.20 Dysphagia.  Medicare requires a secondary diagnosis as well in order to meet medical necessity.  If the patient has Dysphagia....then is it safe to also say the patient has a feeding problem??  Documentation doesn't say that specifically.  My argument is that Dysphagia and feeding problem are not the same and that since the physician has not documented "feeding problem" and the study was essentially negative....we cannot add "feeding problem".  I have seen coders add the 783.3 feeding problem automatically.  I just don't feel good about doing that.  I am open for suggestions on this and would appreciate some feedback.  I definitely don't want this to bite later.  

Thanks in advance for your assistance.


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## TonyaMichelle

Does she have a personal history of digestive system disorders, if so I would try V12.70 or maybe a code from category V71.X (Observation and evaluation for suspected conditions not found)


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## TracieHewitt

We are actually coding for the Radiologist with the -26 modifier only.  So, I don't have information regarding previous history.  Unfortunately, neither the V12.70 nor the V71.X qualify as an acceptable secondary diagnosis by Medicare.  Coders are adding 783.3 feeding problem because they know that it meets medical necessity as a secondary code with dysphagia.  That's the issue I have.....they are adding this diagnosis because they know it will get the claim paid.  I'm just running into the argument with co-workers stating that Dysphagia would indicate a feeding problem.  I disagree....if the two were the same, there wouldn't be separate ICD 9 codes for each diagnosis.


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## ajs

TracieHewitt said:


> We are actually coding for the Radiologist with the -26 modifier only.  So, I don't have information regarding previous history.  Unfortunately, neither the V12.70 nor the V71.X qualify as an acceptable secondary diagnosis by Medicare.  Coders are adding 783.3 feeding problem because they know that it meets medical necessity as a secondary code with dysphagia.  That's the issue I have.....they are adding this diagnosis because they know it will get the claim paid.  I'm just running into the argument with co-workers stating that Dysphagia would indicate a feeding problem.  I disagree....if the two were the same, there wouldn't be separate ICD 9 codes for each diagnosis.



Can you contact the ordering provider and ask if there are other conditions related to the dysphagia?  Let them know you need medical necessity to get the test paid by Medicare.  You must have an LCD that requires the second code because I did not find and NDCs for this code and my local area does not have an LCD for this.


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## TracieHewitt

We get the reports from the Hospital.....we can inquire with them for more info.   Medicare PGBA does list an LCD/NCD for North Carolina.  I just wanted to be sure I was doing the right thing by NOT assuming that the patient has a feeding problem just because they have dysphagia.  I can see where someone would think that if a person has dysphagia (difficulty swallowing)...then they must have feeding problems as well.   I just don't feel it is ethical to assume that myself.


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## TonyaMichelle

I would contact the patient's physician who referred her to the radiologist for the Barium Swallow and query the physician for any related past or present history that would require the medical necessity. Maybe, weight loss or nutrition deficiency, GERD, esophagitis, ear, nose or throat dx's etc.


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## TracieHewitt

Thank you all so much for the feedback.


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