Fees:
Optimize Reimbursement for Swallowing Test
Published on Wed Mar 01, 2000
When billing for their otolaryngologists involvement in fiberoptic, or functional, endoscopic evaluation of swallowing (FEES), coders need to determine which procedures or services actually were performed and which codes will be recognized by carriers. But this can be difficult for several reasons:
1. CPT has yet to establish a code for this service;
2. Medicare and other carriers differ concerning which existing codes should be used; and
3. FEES is sometimes used to describe other swallowing evaluation treatment and services.
Swallowing studies commonly are performed on patients who have been intubated for a long time and have problems eating. The oldest and most common way to evaluate the patients swallowing ability is a barium study, which usually is performed by a radiologist and a speech pathologist. Video fluoroscopy, a more advanced evaluation method that allows video to be recorded of the patients swallowing many different substances, also is typically performed by the radiologist in conjunction with the speech pathologist.
The FEES study is another way to evaluate swallowing that often is used when these two radiological services cant be performed. In this evaluation, an otolaryngologist usually works alongside a speech pathologist. The otolaryngologist will perform a flexible laryngoscopy while the speech pathologist performs the actual swallowing evaluation. A flexible fiberoptic endoscope is introduced transnasally into the patients hypopharynx by the otolaryngologist, who can then view laryngeal and pharyngeal structures. The patient is then led through various tasks to evaluate the sensory and motor status of the pharyngeal and laryngeal mechanism. Food and liquid boluses are given to the patient to determine the integrity of the pharyngeal swallow.
The examination provides information on the patients ability to protect the airway and to initiate a prompt swallow without spilling material into the hypopharynx, among other things. The most critical finding is aspiration, according to an Aetna US Healthcare coverage policy bulletin, and FEES is able to detect this with good sensitivity.
The most common reason for a FEES evaluation is difficulty in swallowing (787.2, dysphagia), though some neurologic and other disorders also may lead to a swallowing evaluation and/or treatment, says Margaret M. Hickey, RN, MSN, MS, president of the Society of Otorhinolaryngology and Head-Neck Nurses and clinical oncology director at the Tulane Cancer Center in New Orleans.
Coding the Services
Like the barium study, the FEES study is a combination of two or more services. Because there currently is no CPT code for FEES, the components of the study must be broken out and coded separately; alternatively, some Medicare carriers prefer the service to be coded with one unlisted code.
The following codes may apply to the FEES study:
31575laryngoscopy; flexible fiberoptic; diagnostic
92520laryngeal function studies
92525evaluation of swallowing and oral function
for feeding
92526treatment of swallowing dysfunction and/or
oral function for feeding
31599unlisted procedure, larynx
Note: If the FEES evaluation is performed before or after either a barium swallow or video fluoroscopy test, the following codes also may apply: 70370 (radiologic examination; pharynx or larynx, including fluoroscopy and/or magnification technique); 70371 (complex dynamic pharyngeal and speech evaluation by cine or video recording) (for video fluoroscopy); 74230 (swallowing function, pharynx and/or esophagus, with cineradiography and/or video) (for straight barium swallow test).
Depending on the situation, the otolaryngologists role may vary when a FEES evaluation is performed, says Cheryl Odquist, CPC, a coder and compliance officer with California Healthcare Medical Billing, a medical billing company in San Diego. Odquist notes that although speech pathologists typically perform the evaluation component of FEES, they cannot provide the technical component of a diagnostic test without some level of supervision, according to guidelines in the Medicare Carriers Manual. Because a flexible laryngoscopy is a necessary component of FEES, the otolaryngologist must perform the laryngoscopy while the speech pathologist evaluates the swallowing ability of the patient.
If the speech pathologist and otolaryngologist are not in the same practice, only the speech pathologist can bill 92525, Odquist says, pointing to guidelines in the Medicare Billing Guide and the Medicare Correct Coding and Payment Manual, which state that 92525 may be reported only by the person who performed the actual swallowing evaluation.
The otolaryngologist, meanwhile, should bill for the laryngoscopy (31575). He or she also may bill for evaluation and management (E/M) services, but only if a significant examination is performed before or after the FEES evaluation. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be attached to the E/M code.
Note: If the speech pathologist is part of the otolaryngologists practice, or if the otolaryngologist performs the swallowing evaluation, then all the CPT codes may be billed on the same HCFA 1500 claim form.
For example, a primary care physician asks an otolaryngologist to see an 86-year-old female stroke patient in the hospital who has difficulty swallowing and currently is using a feeding tube. A modified barium swallow test, which demonstrated silent aspiration with thickened liquids, already has been performed. The pre- and postoperative diagnosis is dysphagia.
The otolaryngologist decides to perform a FEES exam in conjunction with a hospital-based speech pathologist. The speech pathologist evaluates the patient while the otolaryngologist handles the scope. The evaluation indicates that the woman is having problems initiating her swallow, probably due to her stroke. The otolaryngologist reports that the patient may not be able to maintain an adequate diet unless she is supervised continually.
In this situation, the otolaryngologist should be able to bill both for a consult (99251-99255) and a flexible laryngoscopy (31575). Because the evaluation was performed by the speech pathologist, who is not part of the otolaryngologists practice, that service cannot be billed, Odquist says. (For more information on billing, see the article Documentation Is Crucial With Medicare Revision When Coding for Consultations on page 27 of the October 1999 Otolaryngology Coding Alert.)
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Determine Your Carrier's FEES Reimbursement Policies
Some carriers accept claims for fiberoptic endoscopic evaluation of swallowing (FEES), while others do not cover the procedure or want it billed with an unlisted code, or both. In addition, many Medicare carriers have policies in place, not for FEES (which they refer to as FEESS, or fiberoptic endoscopic evaluation of swallowing safety), but for FEESST (fiberoptic endoscopic evaluation of swallowing with sensory testing). In a FEESST evaluation, sensory testing is incorporated into the FEES exam.
For example, Aetna US Healthcare, a commercial carrier, has deemed FEES the preferred test over videofluoroscopy (barium swallow) in the evaluation of a swallowing disorder under certain conditions. Many Medicare carriers, however, do not appear to agree with Aetna or, for that matter, with each other.
In its Medicare policy bulletin on dysphagia (G-37), Xact Medicare Services, the Part B carrier in Pennsylvania, instructs physicians to bill FEESS using unlisted code 31599 (unlisted procedure, larynx) and states that the FEESS procedure will incorporate both the placement of the flexible fiberoptic laryngoscope and the evaluation of swallowing and oral function for feeding ... The [unlisted] procedure code encompasses the entire procedure.
The policy bulletin goes on to state that FEESS and FEESST procedures are reimbursable only to physicians. Services of speech pathologists [SP] may be billed by physicians only under [Medicares] incident to guidelines, which means that the SP must be part of the physicians staff and operate under the same tax ID number for the physician to receive Medicare reimbursement; the SP also must be specially trained and credentialed and perform these services under the direct supervision of the physician. The policy also states that the clinical efficacy and applicability of the addition of sensory testing to the FEESS procedure has not been determined, and that FEESST services will not be reimbursed at a higher rate than the FEESS procedure.
Finally, the bulletin states that code 92525 may be reported when the medical record indicates that a non-instrumental examination has been performed.
Louisiana Medicare, meanwhile, has no FEES policy per se. But it has issued a policy on FEESST that states: [FEESST] is an extremely complicated way to obtain information that can be more readily obtained by using a barium swallow study. Given that the barium swallow study is more accurate and costs less, due to recommendations of our Carrier Advisory Committee, Louisiana Part B Carrier is not covering FEESST. In the same bulletin, Louisiana Medicare instructs providers to use unlisted code 92599 (unlisted otorhinolaryngological service or procedure) to report the service.
For its part, Empire Medicare Services, the Part B carrier in New York City, will pay for a FEESST evaluation. Empire also allows providers to bill using 31575 and 92525. In fact, Empire notes that 92520 and 92525 normally are bundled, but if the sensory test (FEESST) evaluation is performed, and there is documented assessment of laryngopharyngeal sensory discrimination (92520) in addition to oropharyngeal evaluation of swallowing (92525), both codes may be used with modifier -59 (distinct procedural service) attached to procedure code 92520.
Empire notes the service requires a formal descriptive narrative that should include the primary diagnosis and resulting secondary condition. Details of the exam should be included, and in the case of a FEESST evaluation, the sensing threshold should be stated.
Because these policies vary from carrier to carrier, and in the absence of a single code either for the FEES or FEESST evaluation, otolaryngologists should call the carrier in question before proceeding.
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