LCD L33449: Swallowing Studies for Dysphagia

This LCD describes Medicare coverage for instrumental assessment of swallowing. Instrumental assessment of swallowing is indicated for either the evaluation of a patient with dysphagia who has a pharyngeal dysfunction or who is at risk for aspiration. Such study is indicated after clinical (noninstrumental) examination identifies an issue that cannot be resolved without further assessment.

The swallowing study, also known as the Modified Barium Swallow (MBS), is a videofluoroscopic, radiographic test that differs from the traditional barium swallow procedures (e.g., pharyngoesophagram and upper gastrointestinal series) in both procedure and purpose. During the procedure, the patient is seated in an upright or semi-reclining position and given various quantities and textures of food and/or liquids mixed with a contrast material. The procedure includes observation of containment of the food/liquid in the oral cavity, mastication, tongue mobility during oral bolus transport, elevation and retraction of the velum, tongue base retraction, upward and forward movement of the hyoid bone and larynx, laryngeal closure, pharyngeal contraction, and extent and duration of pharyngoesophageal segment opening. The presence, timing and cause of penetration or aspiration into the upper airways are observed. Observations of esophageal clearance in the upright position, sensation and muscle strength may be measured directly or inferred. The videofluoroscopic swallowing study is a collaborative study that can be performed by a speech-language pathologist and a radiologist.

Among the important clinical syndromes that contribute to the presentation of dysphagia and where instrumental assessment of swallowing may be helpful are:

• Patients with stroke or other Central Nervous System (CNS) disorder with associated impairment of speech and swallowing.

• Patients with surgical ablation or radiation due to head and neck cancer with documented difficulty in swallowing.

• Patients without obvious CNS disorder, but with documented difficulty in swallowing.

• Patients with generalized debilitation and with difficulty swallowing food.

• Patients with neuromuscular diseases and rheumatologic diseases known to cause dysphagia.

• Patients with a clinical history of aspiration or a history of aspiration pneumonia.

• Patients with head or neck (throat) injury, including peripheral nerve injury from any cause.

Concerns have been expressed that the use of such services in a mobile setting lacks evidence of medical effectiveness. Questions of patient safety have yet to be resolved for these types of procedures to be performed in a Skilled Nursing Facility (SNF), nursing home or home environment, thus requiring physician presence during the procedure in such settings.

This procedure will be reimbursed only when medically necessary and performed in the following places of service:

• Office (11)

• Off Campus-Outpatient Hospital (19)

• Inpatient Hospital (21)

• On Campus-Outpatient Hospital (22)

• Emergency Room Hospital (23)

• Comprehensive Inpatient Rehabilitation Facility (61)

• Comprehensive Outpatient Rehabilitation Facility (62)

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