Peach visualized in the vallecula during a FEES (something we couldn't see without an instrumental assessment)
Are Instrumental Assessments Necessary?
The short answer to this questions.... YES!
According to Medicare guidelines, the therapist must document the patient’s functional limitations in terms that are objective and measurable. The therapist must document the therapeutic short and long term goals in terms that are objective and measurable. Dysphagia services are not covered when the documentation fails to support that the functional ability or medical condition was impaired to the degree that it required the skills of a therapist. This is why we need visualization through an instrumental assessment! We need to be able to identify functional limitations and justify need for treatment. This simply cannot be done at bedside alone.
Dysphagia Evaluation Codes:
CPT 92610 - Evaluation of oral and pharyngeal swallowing
This evaluation is a clinical (usually bedside) one that does not involve the interpretation of dynamic radiologic studies or endoscopic studies.
The evaluation typically includes a bedside assessment of oral-motor functioning and signs and symptoms of pharyngeal dysphagia.
The evaluation is covered again after treatment has been initiated only if there is a change in the patient's overall condition of such significance that the plan of care cannot meet the beneficiary's goals with re-evaluation.
According to Medicare, Additional Documentation Requirements May Include:
History, Oral motor exam, Positioning, Current eating status including onset and duration of problem, Clinical observations such as: Presence of a feeding tube; Paralysis; Oral, pharyngeal, laryngeal as diagnosed, Coughing or choking; Oral motor structure and function; Positioning; Laryngeal function and vocal quality and loudness; and Cognition and communication skills and
Diagnosis that describes the phase of swallow affected
So, how do we get the information to accurately diagnose swallowing and describe the phase of swallow affected and its severity? We include Recommendations for further assessment
Dysphagia Instrumental Assessment
An instrumental assessment (e.g. Modified Barium Swallow Study, Flexible Fiberoptic Endoscopic Evaluation of Swallowing) may be indicated for patients with suspected (e.g. observations by clinical or support personnel of choking with meals, excessive drooling, etc.), or who are at high risk for pharyngeal dysphagia. The final analysis and interpretation of a instrumental assessment should include a definitive diagnosis, identification of the swallowing phase(s) affected, and a recommended treatment plan, including compensatory swallowing techniques and/or postures and food and/or fluid texture modification. If there is a suspected swallowing issue, an instrumental will help to guide treatment and provide the Speech Therapist with the documentation that will justify a plan of care.
CPT 92612 - Flexible Fiberoptic Endoscopic Evaluation Of Swallowing By Cine Or Video Recording
Endoscopic evaluation of swallowing by cine or video recording (also called Fiberoptic Endoscopic Evaluation of Swallowing (FEES) utilizes the fiberoptic nasopharyngolaryngoscope to evaluate the pharyngeal swallow. Detailed information regarding swallowing function and related functions of structures within the upper aerodigestive tract are obtained (Remember, this is what we need to ethically and appropriately back up our rational for treatment). Therapeutic maneuvers are attempted during this examination to determine a safe diet and to maximize the efficiency of the swallow.
This assessment is covered typically after the therapist determines, based on the results of the initial evaluation/screening (CPT 92610) that the patient requires and could benefit from further evaluation and treatment. This evaluation can be covered more than once if the documentation supports there has been significant clinical change that would impact the course of therapy, including progress and/or regression.
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