Eli's Rehab Report

A good team effort between an SLP and a radiologist is not a bad thing

You no longer have to trip over CMS' rules covering MBS dysphagia evaluations. Get the experts' take on what Medicare considers proper supervision for modified barium swallow (MBS) tests.

The pressing question: Does a physician (radiologist) need to be present for MBS procedures? "Professional guidelines recommend that the service be provided in a team setting with a physician/NPP who provides supervision of the radiological examination and interpretation of medical conditions revealed in it," says the Medicare Benefit Policy Manual, chapter 15, section 230.3, page 148.

Translation: By using the word "recommends" instead of "requires," CMS keeps its ruling somewhat broad and leaves the real decision-making up to individual states that choose to go stricter. In other words, CMS doesn't have a problem if you do the procedure without a radiologist in the room.

Always Follow the Stricter Ruling

If your state decides to take a firmer stance on the supervision issue, you must follow its law first. For example, the state of Arizona requires that a radiologist be present during an MBS test.

"In fact, our state board requires that the physician be the one actually pushing the fluoro," says Kathryn Hammond, MS, CCC, a practicing speech-language pathologist at Havasu Regional Medical Center in Lake Havasu City, Ariz. In this case, providers in Arizona (and other states with stricter practice acts) must adhere to these laws even though CMS doesn't require this level of supervision.

Don't miss: Your payer also may have stricter requirements, which you must follow as well. For example, Medicare fiscal intermediary Mutual of Omaha's local coverage determination says, "The MBS must be conducted and interpreted by a radiologist with the assistance and input from the physician and/or speech pathologist."

Be sure to check your state practice act and payer's LCD for language defining the required level of supervision. In Mutual of Omaha's case, "direct supervision" is required, and the FI defines this as "the physician being present within the same office suite, available and able to intervene." And providers must document the supervision as well.

Don't Be Lax if Your State's Relaxed

If you've done all your homework searching your state practice act and payer policies for MBS supervision requirements and don't see any, you may want to think twice before throwing away the idea of physician supervision. "The reason our professional guidelines recommend physician supervision is that the SLP is looking at the swallowing function, and there could be other structural abnormalities a physician's eye could spot," says Nancy B. Swigert, MA, CCC/SLP, BRS-S, a board-recognized specialist in swallowing and president of Swigert & Associates Inc. in Lexington, Ky
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"We don't diagnose esophageal disorders, so if a problem comes up like cricopharyngeal hypertrophy or an osteophyte, the radiologist is the one who knows all the anatomic details and can determine better, for example, if an osteophyte is impeding the passage of material to the esophagus," Hammond says.

Tricky: The trend in many states' practice acts is to have the physician involved less and less. "In some cases, the SLP has lots of experience with videofluoroscopic studies, and the physician opts not to go in on it because the procedure is time-consuming," Swigert says. This may also be a growing trend because of the hassle to bring a physician along for a mobile MBS procedure.

If your state or payer is silent, the decision is ultimately up to you, but just remember that the profesprofessional recommendations are there for a reason, and following them may protect you if something goes amiss.

Bottom line: Two heads are better than one, and a team collaborating, each with his own specialty's knowledge, is ultimately better for the patient. "I have an excellent working relationship with all three radiologists in our facility -- we collaborate during the study, and they also count on me to keep them updated on the latest research in normal swallowing physiology," Hammond says.