Gastroenterology Coding Alert

Make sure you specify type.

Diagnosing dysphagia is often not cause for alarm among gastroenterology practices. Occasional difficulty in swallowing may simply occur when you eat too fast or don't chew your food well enough. But persistent difficulty in swallowing may indicate a serious medical condition requiring treatment. For diagnostic gastroenterology, dysphagia is considered as an important symptom for diseases of the esophagus.

If you're not careful enough, you might get lost on the sea of options available in reporting dysphagia diagnoses and procedure. Draw up more reserved ammo by keeping in mind these 3 tips.

1. Fit Diagnosis to Its Proper Type

Physicians usually direct patients who complain about any type of upper throat swallowing problem to a speech-language pathologist (SLP) for an appropriate swallow evaluation. SLPs are the ones who actually diagnose dysphagia, determine what type (oral, pharyngeal, or oropharyngeal) and develop a treatment plan, says Christine Lundblad, MA, CCC-SLP, a speech-language pathologist at Promise Hospital in Phoenix.

The gastroenterologist should refer to the SLP report, and note which dysphagia phase she is treating or evaluating. If he has not been able to determine the specific type of dysphagia, you should report the unspecified ICD-9 code 787.20 (Dysphagia, unspecified). Otherwise, you have the option of using any of the four ICD-9 codes that specify a type, including:

• 787.21, Dysphagia, oral phase (oral dysphagia), an inability to coordinate chewing and swallowing a bolus of food placed in the mouth;
• 787.22, Dysphagia, oropharyngeal phase (oropharyngeal dysphagia), describes problems that occur as a food bolus leaves the mouth and enters the pharynx;
• 787.23, Dysphagia, pharyngeal phase (pharyngeal dysphagia), an impairment of strength, timing, and/or coordination to propel a food bolus through the pharynx into the esophagus while closing off the entrance to the larynx during the act of swallowing. The pharyngeal phase is of particular importance as without the laryngeal protective mechanisms, aspiration is most likely to occur during the pharyngeal phase.
• 787.24, Dysphagia, pharyngoesophageal phase (pharyngoesophageal dysphagia), an impairment of the passage of a bolus through the upper esophageal sphincter into the esophagus.

2. One CPT Fits All With 92526

When reporting treatments associated with dysphagia related to any of the upper throat mechanics, all you have to remember is the lone code 92526 (Treatment of swallowing dysfunction and/or oral function for feeding). The National Government Services LCD states: "CPT code 92526 is a comprehensive code that includes most aspects of dysphagia treatment. Do not use additional CPT codes in combination with 92526 when the focus of the treatment is for swallowing. Do not use the 97xxx series of codes when billing for dysphagia treatment. CPT code 92526 is an untimed code, billed as 1 unit per day."

According to Coding Code Initiatives (CCI), the following partial list of codes will be denied when submitted for payment on the same date of service as 92526:

• 92511 -- Nasopharyngoscopy
• 92520 -- Laryngeal function studies
• 97032 -- Electrical stimulation
• 97110 -- Therapeutic exercises
• 97112 -- Neuromuscular reeducation
• 97150 -- Group therapeutic procedures
• 97530 -- Therapeutic activities
• 97532 -- Cognitive skills development.

Payoff: The Medicare rate for dysphagia treatment is about $102 (based on RVU of 2.77 and a conversion factor of $36.8729). The treatment plan for dysphagia can include further diagnostic testing, diet/liquid modifications, oral motor exercises,  deep pharyngeal neuromuscular stimulation (DPNS), or neuromuscular electrical stimulation (NMES).

3. Support Treatment Code with DPNS Therapy

Since treatment for pharyngeal dysphagia (787.23) could involve DPNS therapy (direct neuromuscular stimulation to the pharyngeal musculature), you should consider reporting DPNS alongside the treatment procedure without worrying that you won't get paid for it.

There is a catch, however. You can bill DPNS only in addition to a covered care service (e.g., 92526). DPNS therapy is noncovered because its efficacy has not been clearly demonstrated as reasonable and necessary. Its use alongside a proper treatment code will not be cause for any denial.

Case-to-case TENS Treatment: Ensure Medical Necessity First

A physician may also include transcutaneous electrical nerve stimulation (TENS) in the treatment plan. You have three code options to report this service, including:

• 64550 -- Application of surface (transcutaneous) neurostimulator;
• 97014 -- Application of a modality to 1 or more areas; electrical stimulation (unattended);
• 97032 -- Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes.

Warning: Some payers consider the clinical efficacy and utility of this service to be unproven, says Marvel Hammer, RN CPC CCS-P ACS-PM CHCO, owner of MJH Consulting in Denver. However, because the code for dysphagia treatment is a comprehensive code that includes all treatment approaches, payment may be made for other medically necessary dysphagia treatments.