Neurology & Pain Management Coding Alert

Comprehensive treatment code is key to pay on  NMES, TENS, DPNS claims.

Considering the close relationship between difficulty swallowing and multiple sclerosis (MS), you should get a handle on coding dysphagia from complaint to treatment.

The swallowing disorder (dysphagia) that many MS patients experience is far more frequent than expected, according to doctors reporting in the December 2008 journal Neurological Sciences. Dysphagia, difficulty with swallowing, is considered a dangerous condition from its onset because of its potentially serious complications, the physicians report.

Map Dysphagia Dx to Specific Type If Known

If a person complains to his doctor about any type of swallowing problem, the first thing that is usually recommended is a swallow evaluation by a speech-language pathologist (SLP), says Christine Lundblad, MA, CCC-SLP, a speech-language pathologist at Promise Hospital in Phoenix. We are the ones who actually diagnose dysphagia, determine what type (oral, pharyngeal, or oropharyngeal) and develop a treatment plan.

When the neurologist refers a patient for dysphagia and has not been able to determine the specific type of dysphagia, use the unspecified ICD-9 code for dysphagia: 787.20  (Dysphagia, unspecified). If the medical record shows the problem phase, youll instead use a specific ICD-9 code that represents the dysphagia type. In your neurologists notes, look for these terms that indicate which phase the physician is evaluating and/or treating.

 " Oral dysphagia (787.21  Dysphagia, oral phase) is as an inability to coordinate chewing and swallowing a bolus of food placed in the mouth.
 " Oropharyngeal dysphagia (787.22,  Dysphagia, oropharyngeal phase)  describes problems that occur as a food bolus leaves the mouth and enters the pharynx.
 " Pharyngeal dysphagia (787.23,  Dysphagia, pharyngeal phase) is 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.

The phase of swallowing in the upper one-third of the esophagus has been described as the pharyngoesophageal (787.24,  Dysphagia, pharyngoesophageal phase), referring to passage of a bolus through this portion of the esophagus. When passage of a bolus through the upper esophageal sphincter into the esophagus is impaired, the impairment has been referred to as upper esophageal dysphagia, or more currently termed pharyngoesophageal dysphagia.

Roll Treatments into 1 Code

The treatment plan can include further diagnostic testing, diet/liquid modifications, oral motor exercises, deep pharyngeal neuromuscular stimulation (DPNS), or neuromuscular electrical stimulation (NMES).

Many Medicare local coverage determinations (LCDs) direct you to report 92526 (Treatment of swallowing dys-function and/or oral function for feeding) with one unit of service per day for treatments associated with dysphagia.

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.

Receive Pay With Noncovered DPNS Through Covered Care

Treatment for pharyngeal dysphagia (787.23) might involve DPNS therapy using direct neuromuscular stimulation to the pharyngeal musculature. The goal is to restore muscle strength, endurance, pharyngeal reflex responses, and pharyngeal reflex coordination. This should create a restored, coordinated swallow response.

Catch: Youll receive payment for DPNS, however, only when the patient also receives a covered treatment. Because efficacy for DPNS treatment of dysphagia has not been clearly demonstrated as reasonable and necessary, DPNS for dysphagia treatment is not covered. If DPNS is used in addition to the reasonable and necessary standard of care dysphagia treatment (92526), its use will not cause denial of the otherwise reasonable and necessary care.

Check TENS Coverage or Rely on 92526

Transcutaneous electrical nerve stimulation (TENS) requires one of three codes --  64550, 97014, or 97032. A TENS unit transmits small electrical pulses to electrodes attached to the skin, which transmit an electrical pulse to the underlying peripheral nerves your neurologist wants to stimulate. Possible codes to report for your neurologists services include:

 " 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.

Watch out: 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.