Eli's Rehab Report

Therapists and physiatrists who perform fiberoptic endoscopic swallowing evaluations, take note: You don't need to append modifier -26 (Professional component) when reporting the new codes 92613, 92615 and 92617, because they already represent the physician's interpretation and report. Likewise, therapists who actually perform the tests can report specific codes (92612, 92614 and 92616), eliminating the need for modifier -TC (Technical component).

Practitioners who performed these tests in the past had to make do with the broad code 92525 (Evaluation of swallowing and oral function for feeding), which CPT deleted this year, or HCPCS codes G0193-G0196, says Steven White, director of healthcare economics and advocacy at the American Speech-Language-Hearing Association, which submitted the new codes to the CPT Review Panel. "These tests are extremely useful when diagnosing conditions associated with swallowing dysfunction," such as stroke (436).

The AMA's CPT Changes 2003: An Insider's View suggests that you might use 92614-92617 (descriptors of these codes are on page 2) to evaluate a stroke patient's ability to protect his airway from ingestants and secretions and avoid respiratory arrest. "Occupational therapists provide dysphagia (swallowing) services, both evaluation and treatment, usually related to eating and feeding dysfunction," says Judith Thomas, MGA, reimbursement policy director at the American Occupational Therapy Association (AOTA).

Physical and occupational therapists and speech-language pathologists (SLPs) who perform these evaluations should only bill the test's technical portion, referenced by codes 92612, 92614 and 92616. Because CPT breaks these codes out from the physician's interpretation, however, do not append modifier -TC to the evaluation services. "This is a break from the way most practitioners are accustomed to performing such tests," White says. "But because the physicians have a separate code for interpretation, these modifiers are not necessary."

Physicians later review the swallowing or laryngeal function evaluation tape and write a report. Bill for these services using 92613, 92615 and 92617. Because most carriers have not yet published medical review policies covering these new codes, insurer's guidelines are still unclear. Because CPT Changes suggests that these services will benefit stroke (436) and paralysis patients, however, those ICD-9 codes will most likely support medical necessity.

For example, Aetna's "Speech Therapy for Dysphagia (787.2)" policy covers patients with strokes, brain injuries, nervous system diseases such as cerebral palsy (343.x), head and neck injuries, and many other diagnoses.

"Some occupational therapists (OTs) have had trouble getting paid for treating dysphagia because the financial intermediary did not find a specific reference to OTs and dysphagia in medical literature," Thomas says. "The reference is actually there, but CMS leaves coverage up to the carrier."

OTs who treat dysphagia patients should appeal such denials and request specific carrier documentation that prohibits them from billing these codes.

Some Medicaid carriers require that speech and occupational therapists who treat hospital patients bill the hospital directly, similar to the consolidated billing requirements that therapists must undertake with skilled nursing facilities.

According to Idaho's "Medicaid Billing and Reimbursement for Outpatient Occupational and Speech Therapy" policy, "Independent providers of these two services may not bill Medicaid directly, but may serve Medicaid-eligible individuals under contract with hospitals."

Speech and occupational therapists should check state carrier's contracts before reporting these codes. If a federal carrier or private insurer prohibits you from billing the codes directly, contact the hospitals where you provide the most services to find out how to set up a contractual relationship.