Local Coverage Determination (LCD): Speech-Language Pathology (SLP) Services: Dysphagia; Includes VitalStim Therapy (L34891)

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1 Local Coverage Determination (LCD): Speech-Language Pathology (SLP) Services: Dysphagia; Includes VitalStim Therapy (L34891) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Novitas Solutions, Inc. Contract Number Contract Type A and B MAC Jurisdiction J - L LCD Information Document Information LCD ID L34891 Original ICD-9 LCD ID L27537 LCD Title Speech-Language Pathology (SLP) Services: Dysphagia; Includes VitalStim Therapy AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. Printed on 11/16/2015. Page 1 of 6 Jurisdiction Pennsylvania Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 10/01/2015 Revision Ending Date Retirement Date Notice Period Start Date Notice Period End Date

2 CMS National Coverage Policy This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for speech language services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for speech/language services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies regarding speech/language services are found in the following Internet-Only Manual (IOMs) published on the CMS Web site: CMS Internet-Only Manual (IOM) Publication , Chapter 15, Section 220 and 230 CMS IOM Publication , Chapter 1, Section CMS IOM Publication , Chapter 5 Social Security Act (Title XVIII) Standard References: Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations. Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim. Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. Note: This LCD addresses treatment of swallowing dysfunction and/or oral function for feeding. For the treatment of associated problems, for example, feeding difficulty due to paralysis from a stroke, please see the appropriate therapy LCD. Please refer to LCD L35070, Speech-Language Pathology (SLP) Services: Communication Disorders for services related to communication disorders. Dysphagia, or difficulty in swallowing, can cause solids or liquids to enter the airway, resulting in coughing, choking, aspiration, or inadequate nutrition and hydration with resultant weight loss, failure to thrive, pneumonia, and death. Patients' symptoms may include the sensation of food "sticking", "stopping", or "hanging up", which is usually felt above or at the level of the abnormality. Dysphagia may involve the oral cavity, pharynx, esophagus, gastroesophageal junction, or proximal stomach. There are multiple factors that may cause dysphagia to occur. Some examples include: complex neurological and/or structural impairments including head and neck trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, dementias and encephalopathies. Coverage Limitations VitalStim is a type of neuromuscular electrical stimulation therapy for the treatment of dysphagia, which uses small electrical currents to stimulate the muscles responsible for swallowing. VitalStim is used in conjunction with traditional dysphagia treatment of oromotor exercises, and swallowing strategies. Based upon review of the scientific and clinical literature, the clinical efficacy and clinical utility of this service remains unproven. Recent studies with the use of this surface electrical stimulation treatment show a lowering of the hyoid bone during swallowing, which may actually be harmful to the patient. Therefore, VitalStim therapy will not be covered by Medicare and treatment will be deemed not reasonable and necessary in the treatment of patients with dysphagia. Printed on 11/16/2015. Page 2 of 6

3 Because the code for dysphagia treatment is a comprehensive code which includes all treatment approaches, payment may be made for other medically necessary dysphagia treatments. As published in CMS IOM , Chapter 13, Section , in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). 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, that 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 needs. At least as beneficial as an existing and available medically appropriate alternative. Coding Information 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. 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 018x Hospital - Swing Beds 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 074x Clinic - Outpatient Rehabilitation Facility (ORF) 075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 083x Ambulatory Surgery Center 085x Critical Access Hospital 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. Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub , Claims Processing Manual, for further guidance. Printed on 11/16/2015. Page 3 of 6

4 043X Occupational Therapy - General Classification 044X Speech Therapy - Language Pathology - General Classification CPT/HCPCS Codes Group 1 Paragraph: Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. Group 1 Codes: Oral function therapy Evaluate swallowing function ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: Note: No specific ICD-10-CM codes are provided here; the provider is responsible to select codes from the ICD- 10-CM code book appropriate to the year in which the service is rendered and carried out to the highest level of specificity to characterize the problem and support the medical necessity of the services rendered. Group 1 Codes: ICD-10 Codes Description XX000 Not Applicable ICD-10 Codes that DO NOT Support Medical Necessity Group 1 Paragraph: All those not listed under the "ICD-10 Codes that Support Medical Necessity" section of this policy. Group 1 Codes: ICD-10 Additional Information General Information Associated Information Documentation Requirements 1. All documentation must be maintained in the patient s medical record and made available to the contractor upon request. 2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. 3. The submitted medical record should support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. 4. The medical record documentation must support the medical necessity of the services as directed in this policy. Utilization Guidelines In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice. Printed on 11/16/2015. Page 4 of 6

5 Sources of Information and Basis for Decision Contractor is not responsible for the continued viability of websites listed. Ali GN, Wallace KL, Laundl TM, et al. Predictors of outcome following cricopharyngeal disruptions for pharyngeal dysphagia. Dysphagia 1997; 12: Burnett TA, Mann EA, Stoklosa JB, et al. Self-Triggered Functional Electrical Stimulation During Swallowing. J Neurophysiol. 2005; 94: Carnaby-Mann GD and Crary MA. Adjunctive Neuromuscular Electrical Stimulation for Treatment-Refractory Dysphagia. Annals of Otology 2008; 117 (4): Carnaby-Mann GD and Crary MA. Examining the Evidence on Neuromuscular Electrical Stimulation for Swallowing: A Meta-analysis. Archives of Otolaryngology - Head and Neck Surgery 2007; 133: Carter J. Point/Counterpoint: Electrical Stimulation for Dysphagia: The Argument for Electrical Stimulation for Dysphagia. Downloaded from Freed ML, Freed L, Chatburn RL, et al. Electrical Stimulation for Swallowing Disorders Caused by Stroke. Respiratory Care 2001; 46 (5): Gallas S, Marie JP, Leroi AM, et al. Sensory Transcutaneous Electrical Stimulation Improves Post-Stroke Dysphagic Patients. Dysphagia 2009 (Online October 24). Hamdy S, Aziz Q, Rothwell JC, et al. Recovery of Swallowing After Dysphagic Stroke Relates to Functional Reorganization in the Intact Motor Cortex. Gastroenterology 1998; 115: Humbert IA, Poletto CJ, Saxon KG, et al. The Effect of Surface Electrical Stimulation on Hyo-Laryngeal Movement in Normal Individuals at Rest and During Swallowing. J Appl Physiol. 2006; 101: Kanaya F. Effect of Electrostimulation on Denervated Muscle. Clinical Orthopaedics and Related Research 1992; 282: Leelemanit V, Limsakul C, Geater A, et al. Synchronized Electrical Stimulation in Treating Pharyngeal Dysphagia. The Laryngoscope 112 (12): Logemann J. Approaches to management of disordered swallowing. Bailliere's Clinical Gastroenterology 1191; 5: Ludlow CL, Humbert I, Saxon K, et al. Effects of Surface Electrical Stimulation Both at Rest and During Swallowing in Chronic Pharyngeal Dysphagia. Dysphagia 2007; 22(1): Oh B-M, Kim D-Y and Paik, N-J. Recovery of Swallowing Function is Accompanied by the Expansion of the Cortical Map. International Journal of Neuroscience 2007; 117: Park J-W, Oh, J-C, Lee HJ, et al. Effortful Swallowing Training Coupled with Electrical Stimulation Leads to an Increase in Hyoid Elevation During Swallowing. Dysphagia 2009 (Online March 3). Park C, O Neill PA, Martin DF. A Pilot Exploratory Study of Oral Electrical Stimulation on Swallow Function following Stroke: An Innovative Technique. Dysphagia 1997; 12: Yokoyama M, Natsuhiko M, Katsuhiko T, et al. Role of Laryngeal Movement and Effect of Aging on Swallowing Pressure in the Pharynx and Upper Esophageal Sphincter. The Laryngoscope 110 (3); Contractor Medical Directors New Technology Medicine/Surgery Clinical Workgroup Other Contractor Policies Contractor Medical Directors Original JL ICD-9 Source LCD L27537, Speech-Language Pathology (SLP) Services: Dysphagia; Includes VitalStim Therapy Printed on 11/16/2015. Page 5 of 6

6 Revision History Information Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History Number of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a separate and distinct row. Revision History Date 10/01/2015 R1 Revision History Number Associated Documents Attachments Related Local Coverage Documents Related National Coverage Documents Revision History Explanation LCD revised and published on 04/09/2015. LCD revised to create uniform LCD with other MAC jurisdiction. Reason(s) for Change Creation of Uniform LCDs With Other MAC Jurisdiction Public Version(s) Updated on 04/01/2015 with effective dates 10/01/ Updated on 04/02/2014 with effective dates 10/01/ Keywords Read the LCD Disclaimer Printed on 11/16/2015. Page 6 of 6

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