CPT code - 70370, 70371, 74230 - Barium Swallow Studies,



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:
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.
70370©
Throat x-ray & fluoroscopy
70371©
Speech evaluation, complex
74230©
Cine/vid x-ray, throat/esoph

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
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
Dysphagia cerebrovascular disease
507.0
Pneumonitis due to inhalation of food or vomitus
787.20–787.24*
Dysphagia
787.29*
Other dysphagia
Note: Code 787.20*–787.24* and 787.29* as the primary diagnosis requires a secondary (dual) diagnosis from the table below.
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
Late effects of acute poliomyelitis
140.0–140.1
Malignant neoplasm of lip
140.3–140.6
Malignant neoplasm of lip
140.8–140.9
Malignant neoplasm of lip
141.0–141.6
Malignant neoplasm of tongue
141.8–141.9
Malignant neoplasm of tongue
142.0–142.2
Malignant neoplasm of major salivary glands
142.8–142.9
Malignant neoplasm of major salivary glands
143.0–143.1
Malignant neoplasm of gum
143.8–143.9
Malignant neoplasm of gum
144.0–144.1
Malignant neoplasm of floor of mouth
144.8–144.9
Malignant neoplasm of floor of mouth
145.0–145.6
Malignant neoplasm of other and unspecified parts of mouth
145.8–145.9
Malignant neoplasm of other and unspecified parts of mouth
146.0–146.9
Malignant neoplasm of oropharynx
147.0–147.3
Malignant neoplasm of nasopharynx
147.8–147.9
Malignant neoplasm of nasopharynx
148.0–148.3
Malignant neoplasm of hypopharynx
148.8–148.9
Malignant neoplasm of hypopharynx
149.0–149.1
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity or pharynx
149.8–149.9
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity or pharynx
150.0–150.5
Malignant neoplasm of esophagus
150.8–150.9
Malignant neoplasm of esophagus
160.0–160.5
Malignant neoplasm of nasal cavities, middle ear and accessory sinuses
160.8
Malignant neoplasm of nasal cavities, middle ear, accessory sinuses, other
161.0–161.3
Malignant neoplasm of larynx
161.8–161.9
Malignant neoplasm of larynx
195.0
Malignant neoplasm of head, face and neck
196.0
Secondary and unspecified malignant neoplasm of lymph nodes of head face and neck
197.8
Secondary malignant neoplasm of other digestive organs and spleen
210.1–210.9
Benign neoplasm of lip, oral cavity and pharynx
211.0
Benign neoplasm of esophagus
235.6
Neoplasm of uncertain behavior of larynx
239.1
Neoplasm of unspecified nature of respiratory system
300.11
Conversion disorder
332.0–332.1
Parkinson’s disease
333.0
Other degenerative diseases of the basal ganglia
333.2
Myoclonus
333.4–333.6
Other extrapyramidal disease and abnormal movement disorders
333.71
Athetoid cerebral palsy
333.79
Other acquired torsion dystonia
333.81–333.84
Fragments of torsion dystonia
333.89
Other fragments of torsion dystonia
333.90–333.93
Other and unspecified extrapyramidal diseases and abnormal movement disorders
333.99
Other extrapyramidal diseases and abnormal movement disorders
335.20–335.24
Motor neuron disease
340
Multiple sclerosis
341.0–341.1
Other demyelinating diseases of central nervous system
341.20–341.22
Acute (transverse) myelitis
341.8–341.9
Other demyelinating diseases of central nervous system
342.00–342.02
Hemiplegia and hemiparesis
342.10–342.12
Hemiplegia and hemiparesis
342.80–342.82
Hemiplegia and hemiparesis
342.90–342.92
Hemiplegia and hemiparesis
343.8
Other specified infantile cerebral palsy
344.00–344.04
Quadriplegia and quadriparesis
344.09
Other quadriplegia and quadriparesis
358.00–358.01
Myasthenia gravis
359.1
Hereditary progressive muscular dystrophy
434.00–434.01
Cerebral thrombosis
434.10–434.11
Cerebral embolism
434.90–434.91
Cerebral artery occlusion, unspecified
436
Acute but ill-defined cerebrovascular disease
438.11
Aphasia
438.12
Dysphasia
438.13
Late effects of cerebrovascular disease, dysarthria
438.20–438.22
Late effects of cerebrovascular disease (Hemiplegia/hemiparesis)
438.82
Dysphagia cerebrovascular disease
464.01
Acute laryngitis with obstruction
478.30–478.34
Paralysis of vocal cords or larynx
478.6
Edema of larynx
507.0
Pneumonitis due to inhalation of food or vomitus
530.0
Achalasia and cardiospasm
530.13
Eosinophilic esophagitis
530.3
Stricture and stenosis of esophagus
530.4
Perforation of esophagus
530.5
Dyskinesia of esophagus
530.6
Diverticulum of esophagus, acquired
530.81
Esophageal reflux
530.86–530.87
Other specified disorders of esophagus
710.1
Systemic sclerosis
710.3–710.4
Diffuse diseases of connective tissue
783.3
Feeding difficulties and mismanagement
784.49
Other voice and disturbance disorders
784.51
Dysarthria
784.59
Other speech disturbance
787.99
Other symptoms involving digestive system
908.9
Late effect of unspecified injury
933.1
Foreign body in larynx
934.0–934.9
Foreign body in trachea – foreign body in respiratory tree unspecified
V10.02
Personal history of malignant neoplasm, other and unspecified oral cavity and pharynx
V10.21–V10.22
Personal history of malignant neoplasm, other respiratory and intrathoracic organs
V41.6
Problems with swallowing and mastication
V48.3
Mechanical and motor problems with neck and trunk
V67.1
Follow-up examination following radiotherapy

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

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