Radiology Coding Alert

"Confusion about what was studied and recorded when swallowing studies are done causes coding errors that result in denials and loss of reimbursement. Medicare policy outlines three radiologic codes that may be assigned during swallowing studies conducted using videofluoroscopy:

74230: (swallowing function, pharynx and/or esophagus, with cineradiography and/or video).

70371: (complex dynamic pharyngeal and speech evaluation by cine or video recording);

70370: (radiologic examination; pharynx or larynx, including fluoroscopy and/or magnification technique);

Radiology coders express confusion about the distinctions between these codes, particularly between 70371 and 74230. There is significant difference in the relative value units (RVUs) assigned them, as well, which makes it even more important for coders to understand and report these codes correctly. CPT 74230 carries an RVU of 26.38, while 70371 carries a 41.35 value.

Contributing to the confusion are the characteristics these procedures have in common. Each involves the use of fluoroscopy to examine the structure and function of the anatomy found in the mouth and throat during the act of swallowing. Speech pathologists may be involved in both studies. The differences lie in what is studied.

74230Risk for Aspirating Food into Airway. CPT 74230 describes what is often termed a classic modified barium swallow. Pioneered by Jeri Logemann, Ph.D., professor of communication sciences and disorders at Northwestern University and current president of the American Speech, Language and Hearing Association, this study documents how the oral cavity, pharynx and the upper esophagus perform while a patient swallows.

It is most often performed on patients who have had a stroke (436, acute, but ill-defined, cerebrovascular disease; 438.11, late effects of cerebrovascular disease, aphasia; 438.12, late effects of cerebrovascular disease, dysphasia) or who suffer from Parkinsons disease (332.0-332.1). Other diagnosis codes that may be used to justify 74230 include 150.0150.9, malignant neoplasms of esophagus; 235.6, neoplasm of uncertain behavior of larynx; and 507.0, pneumonitis due to solids and liquids, due to inhalation of food or vomitus.

This assessment can be done to evaluate both speech and swallowing problems, she says. It is especially valuable when used to evaluate patients at risk for aspirating food into their airway (trachea and lungs) while eating.

During the exam, videofluoroscopy is used to view the function of the mouth, pharynx (which closes as food progresses through it during the swallow) and cervical esophagus. Graduated amounts of thin liquids and, eventually, solid foods are given to the patient, and his or her ability to swallow each is measured. The radiologist and speech language pathologist conduct a fluorographic study, which is recorded on video for in-depth analysis.

Note: In the past, these studies were recorded using movie film, which is what the term cineradiography refers to in the code description. This technology is rarely used today, now that videography is available.

Generally, a speech pathologist is involved in the modified barium swallow, and the procedural component reflecting his or her services would be assigned 92525. The radiologist performing the fluoroscopy would correctly report 74230.

Two additional codes are often categorizedand confusedwith 74230: CPT 74210 (radiologic examination; pharynx and/or cervical esophagus) and 74220 (esophagus). Also conducted during barium swallowing tests, 74210 and 74220 describe routine fluoroscopic examinations of these anatomical features and generally do not include videotaping. Code 74210 focuses specifically on the pharynx and cervical esophagus, while 74220 comprises four overhead radiographs of the entire esophagus from the mouth to the stomach. Although used to diagnose many of the same conditions as 74230, these do not include the dynamic portion of the study.

70371Assessing Soft Tissues. The focus for CPT 70371 is the evaluation of the movements of the tissues in the mouth and throat, and is most often used for speech evaluation. According to Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based firm that supports 1,000 radiologists and 350 physicians from other specialty areas, patients are asked to say a number of words.

Fluoroscopy is used to record how the tongue, palate and other soft tissues in the mouth function. As the words and sounds are repeated, the speech pathologist and radiologist are able to see where problems may lie, she says. These tests are often conducted on pediatric patients, who may have delays in their speech development (i.e. code 784.5, other speech disturbance [dysarthria, dysphasia, slurred speech]).

Because of the potential for confusion between 74230 and 70371, Parman says the radiologists dictation is vital. The coder needs to know exactly what was studied and recorded to be able to assign the appropriate code, she points out. It should be clear the 74230 is used for swallowing disorders, while 70371 is used for speech evaluation.

70370Seldom-used Code. Categorized by some radiology coders as archaic, 70370 is rarely used. It describes a radiologic exam using fluoroscopy and/or magnification techniques, but does not include the dynamic elements of the speech evaluation codein which the movements of the mouth and tongue are required."