Procedure Code Description
70370 Radiologic examination; pharynx or larynx, including fluoroscopy and/or magnification technique
70371 Complex dynamic pharyngeal and speech evaluation by cine or video recording
74230 Swallowing function, with cineradiography/videoradiography (Video Fluoroscopy)
The videofluoroscopic 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-reclined 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.
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.
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, 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:
- Office (11).
- Inpatient hospital (21).
- Outpatient hospital (22).
- Emergency room hospital (23).
- Comprehensive inpatient rehabilitation facility (61).
- Comprehensive outpatient rehabilitation facility (62).
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 21X, 22X, 23X, 75X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
032X, 044X
CPT/HCPCS Codes
Note:
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Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
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70370©
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Throat x-ray & fluoroscopy
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70371©
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Speech evaluation, complex
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74230©
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Cine/vid x-ray, throat/esoph
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Billing and Coding Guidelines
Comment: A commenter requested the inclusion of three CPT codes 70370 (Radiologic examination; pharynx or larynx, including fluoroscopy and/or magnification technique), 70371 (Complex dynamic pharyngeal and speech evaluation by cine or video recording) and 74230 (Swallowing function, with cineradiography/videoradiography) as well as numerous ICD-9-CM codes to the “ICD-9-CM Codes that Support Medical Necessity” section.
Response: We regret that we are unable to include additional CPT codes without re-sending the LCD for advice and comment. We will consider these codes for inclusion at a later date when the LCD is revised. We have added nine (9) additional ICD-9-CM codes to the LCD from the list of submitted ICD- 9-CM codes because these conditions would nearly always require a dysphagia evaluation and treatment. We did not include the remaining ICD-9-CM codes because the coding convention used in the LCD reflects ICD-9-CM codes that represent a functional problem requiring dysphagia evaluation and treatment. The ICD-9-CM codes we did not add represent underlying medical conditions that may or may not require dysphagia evaluation and treatment. If an evaluation or treatment is required, then patients with these conditions will have a functional diagnosis to support medical necessity.
American Occupational Therapy Association (AOTA) requests Occupational Therapists be included as providers of dysphagia services. Recommendations included adding – Occupational Therapists to section III. Professional qualifications for Providers, Speech-Language Pathologists, and Occupational Therapists. Also, to revise the ‘Incident to’ Benefit section to read: “Swallow evaluations/assessments (CPT codes 74230, 92610, 92611, 92612, 92614 and 92616 may be performed by physicians, NPP, or Speech and Language Pathologists, or Occupational Therapists. When these services are performed by a SLP or OT then billed by Physicians or NPPs, they are covered under the ‘incident to’ provision if the service is rendered in a physician/NPP owned and operated clinic.” Add the following revenue code in the Coding Information section: 043X Occupational Therapy – General Classification. Add occupational therapists to section II.
Instrumental Evaluation/Assessment: “An instrumental evaluation/assessment is not medically necessary if clinical judgment by the Physician or, Speech-Language Pathologist, or Occupational Therapist indicates: and “The instrumental evaluation/assessment of swallowing, the functional physical assessment, interpretation and management of dysphagia when used for diagnostic purposes can be performed and interpreted by Speech-Language Pathologists with certification of clinical competency or Occupational Therapists and it is within their individual state scope of practice law.”
ICD-9-CM Codes That Support Medical Necessity
Comment: A commenter requested the inclusion of three CPT codes 70370 (Radiologic examination; pharynx or larynx, including fluoroscopy and/or magnification technique), 70371 (Complex dynamic pharyngeal and speech evaluation by cine or video recording) and 74230 (Swallowing function, with cineradiography/videoradiography) as well as numerous ICD-9-CM codes to the “ICD-9-CM Codes that Support Medical Necessity” section.
Response: We regret that we are unable to include additional CPT codes without re-sending the LCD for advice and comment. We will consider these codes for inclusion at a later date when the LCD is revised. We have added nine (9) additional ICD-9-CM codes to the LCD from the list of submitted ICD- 9-CM codes because these conditions would nearly always require a dysphagia evaluation and treatment. We did not include the remaining ICD-9-CM codes because the coding convention used in the LCD reflects ICD-9-CM codes that represent a functional problem requiring dysphagia evaluation and treatment. The ICD-9-CM codes we did not add represent underlying medical conditions that may or may not require dysphagia evaluation and treatment. If an evaluation or treatment is required, then patients with these conditions will have a functional diagnosis to support medical necessity.
American Occupational Therapy Association (AOTA) requests Occupational Therapists be included as providers of dysphagia services. Recommendations included adding – Occupational Therapists to section III. Professional qualifications for Providers, Speech-Language Pathologists, and Occupational Therapists. Also, to revise the ‘Incident to’ Benefit section to read: “Swallow evaluations/assessments (CPT codes 74230, 92610, 92611, 92612, 92614 and 92616 may be performed by physicians, NPP, or Speech and Language Pathologists, or Occupational Therapists. When these services are performed by a SLP or OT then billed by Physicians or NPPs, they are covered under the ‘incident to’ provision if the service is rendered in a physician/NPP owned and operated clinic.” Add the following revenue code in the Coding Information section: 043X Occupational Therapy – General Classification. Add occupational therapists to section II.
Instrumental Evaluation/Assessment: “An instrumental evaluation/assessment is not medically necessary if clinical judgment by the Physician or, Speech-Language Pathologist, or Occupational Therapist indicates: and “The instrumental evaluation/assessment of swallowing, the functional physical assessment, interpretation and management of dysphagia when used for diagnostic purposes can be performed and interpreted by Speech-Language Pathologists with certification of clinical competency or Occupational Therapists and it is within their individual state scope of practice law.”
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Report dysphagia with the primary diagnosis of 438.82, 507.0 or 787.20*–787.24* and 787.29.* At least one of the secondary diagnoses from the next list is required for 787.2X (438.82 and 507.0 do not require a secondary diagnosis).
Medicare is establishing the following limited coverage for CPT/HCPCS codes 70370, 70371 and 74230:
Covered for:
438.82
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Dysphagia cerebrovascular disease
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507.0
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Pneumonitis due to inhalation of food or vomitus
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787.20–787.24*
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Dysphagia
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787.29*
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Other dysphagia
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Note: Code 787.20*–787.24* and 787.29* as the primary diagnosis requires a secondary (dual) diagnosis from the table below.
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The following are secondary (dual) diagnoses to be used with 787.20*–787.24* and 787.29* (primary diagnosis) to meet limited coverage for CPT/HCPCS codes 70370, 70371 and 74230:
138
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Late effects of acute poliomyelitis
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140.0–140.1
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Malignant neoplasm of lip
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140.3–140.6
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Malignant neoplasm of lip
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140.8–140.9
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Malignant neoplasm of lip
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141.0–141.6
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Malignant neoplasm of tongue
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141.8–141.9
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Malignant neoplasm of tongue
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142.0–142.2
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Malignant neoplasm of major salivary glands
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142.8–142.9
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Malignant neoplasm of major salivary glands
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143.0–143.1
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Malignant neoplasm of gum
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143.8–143.9
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Malignant neoplasm of gum
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144.0–144.1
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Malignant neoplasm of floor of mouth
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144.8–144.9
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Malignant neoplasm of floor of mouth
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145.0–145.6
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Malignant neoplasm of other and unspecified parts of mouth
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145.8–145.9
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Malignant neoplasm of other and unspecified parts of mouth
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146.0–146.9
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Malignant neoplasm of oropharynx
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147.0–147.3
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Malignant neoplasm of nasopharynx
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147.8–147.9
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Malignant neoplasm of nasopharynx
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148.0–148.3
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Malignant neoplasm of hypopharynx
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148.8–148.9
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Malignant neoplasm of hypopharynx
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149.0–149.1
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Malignant neoplasm of other and ill-defined sites within the lip, oral cavity or pharynx
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149.8–149.9
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Malignant neoplasm of other and ill-defined sites within the lip, oral cavity or pharynx
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150.0–150.5
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Malignant neoplasm of esophagus
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150.8–150.9
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Malignant neoplasm of esophagus
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160.0–160.5
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Malignant neoplasm of nasal cavities, middle ear and accessory sinuses
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160.8
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Malignant neoplasm of nasal cavities, middle ear, accessory sinuses, other
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161.0–161.3
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Malignant neoplasm of larynx
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161.8–161.9
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Malignant neoplasm of larynx
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195.0
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Malignant neoplasm of head, face and neck
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196.0
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Secondary and unspecified malignant neoplasm of lymph nodes of head face and neck
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197.8
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Secondary malignant neoplasm of other digestive organs and spleen
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210.1–210.9
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Benign neoplasm of lip, oral cavity and pharynx
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211.0
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Benign neoplasm of esophagus
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235.6
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Neoplasm of uncertain behavior of larynx
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239.1
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Neoplasm of unspecified nature of respiratory system
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300.11
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Conversion disorder
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332.0–332.1
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Parkinson’s disease
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333.0
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Other degenerative diseases of the basal ganglia
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333.2
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Myoclonus
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333.4–333.6
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Other extrapyramidal disease and abnormal movement disorders
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333.71
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Athetoid cerebral palsy
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333.79
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Other acquired torsion dystonia
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333.81–333.84
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Fragments of torsion dystonia
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333.89
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Other fragments of torsion dystonia
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333.90–333.93
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Other and unspecified extrapyramidal diseases and abnormal movement disorders
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333.99
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Other extrapyramidal diseases and abnormal movement disorders
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335.20–335.24
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Motor neuron disease
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340
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Multiple sclerosis
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341.0–341.1
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Other demyelinating diseases of central nervous system
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341.20–341.22
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Acute (transverse) myelitis
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341.8–341.9
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Other demyelinating diseases of central nervous system
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342.00–342.02
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Hemiplegia and hemiparesis
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342.10–342.12
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Hemiplegia and hemiparesis
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342.80–342.82
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Hemiplegia and hemiparesis
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342.90–342.92
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Hemiplegia and hemiparesis
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343.8
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Other specified infantile cerebral palsy
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344.00–344.04
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Quadriplegia and quadriparesis
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344.09
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Other quadriplegia and quadriparesis
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358.00–358.01
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Myasthenia gravis
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359.1
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Hereditary progressive muscular dystrophy
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434.00–434.01
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Cerebral thrombosis
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434.10–434.11
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Cerebral embolism
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434.90–434.91
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Cerebral artery occlusion, unspecified
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436
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Acute but ill-defined cerebrovascular disease
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438.11
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Aphasia
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438.12
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Dysphasia
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438.13
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Late effects of cerebrovascular disease, dysarthria
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438.20–438.22
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Late effects of cerebrovascular disease (Hemiplegia/hemiparesis)
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438.82
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Dysphagia cerebrovascular disease
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464.01
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Acute laryngitis with obstruction
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478.30–478.34
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Paralysis of vocal cords or larynx
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478.6
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Edema of larynx
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507.0
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Pneumonitis due to inhalation of food or vomitus
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530.0
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Achalasia and cardiospasm
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530.13
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Eosinophilic esophagitis
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530.3
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Stricture and stenosis of esophagus
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530.4
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Perforation of esophagus
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530.5
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Dyskinesia of esophagus
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530.6
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Diverticulum of esophagus, acquired
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530.81
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Esophageal reflux
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530.86–530.87
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Other specified disorders of esophagus
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710.1
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Systemic sclerosis
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710.3–710.4
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Diffuse diseases of connective tissue
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783.3
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Feeding difficulties and mismanagement
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784.49
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Other voice and disturbance disorders
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784.51
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Dysarthria
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784.59
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Other speech disturbance
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787.99
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Other symptoms involving digestive system
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908.9
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Late effect of unspecified injury
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933.1
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Foreign body in larynx
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934.0–934.9
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Foreign body in trachea – foreign body in respiratory tree unspecified
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V10.02
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Personal history of malignant neoplasm, other and unspecified oral cavity and pharynx
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V10.21–V10.22
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Personal history of malignant neoplasm, other respiratory and intrathoracic organs
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V41.6
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Problems with swallowing and mastication
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V48.3
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Mechanical and motor problems with neck and trunk
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V67.1
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Follow-up examination following radiotherapy
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Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
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