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by Amy Hasselkus and Mark Kander
Electrical stimulation (e-stim) dysphagia treatment may or may not be covered by Medicare and private health plans, even though CMS (Centers for Medicare and Medicaid Services) has provided e-stim coverage and coding rules.
Medicare has not issued a national coverage decision for e-stim, leaving coverage decisions to local Medicare intermediaries and carriers (known as Medicare administrative contractors or MACs). The MACs that have issued or adopted dysphagia coverage policies have stated that research is insufficient to support reimbursement for dysphagia e-stim treatment as a separate swallowing technique. However, because the CPT code for dysphagia treatment is "untimed," the MACs allow e-stim as long as a significant portion of the session utilizes conventional dysphagia treatment techniques.
An untimed code represents a treatment session without regard to its length. Officially, payment covers only the traditional treatment segment. Some MACs require a session length of at least 30 minutes, unless an acceptable justification is documented for a shorter period. It is advised that the non-e-stim portion of a session usually be at least 30 minutes.
Three current procedural terminology (CPT) codes can be considered when performing dysphagia e-stim treatment:
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CPT 92526 (dysphagia treatment session). The average Medicare payment for this code, which is not time-based, is $82.80. Medicare and various other payers have ruled that all treatment that addresses goals in the dysphagia plan of care is billed under CPT 92526. This ruling eliminates the use of a separate e-stim code.
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CPT 97032 (electrical stimulation, manual, each 15 minutes). The geographically adjusted Medicare payment is $16.75 for each 15 minutes. For private health plans that accept this code, CPT 97032 is for face-to-face treatment time; the practitioner cannot be attending other patients. If, during the course of treatment, the practitioner attends other patients, the clock stops until he/she returns to the patient. The common rule for billing a 15-minute code is that direct treatment time may be 8–22 minutes. (Two 15-minute codes can be billed if direct treatment is 23–37 minutes; three 15-minute codes for 38–52 minutes, etc.)
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CPT 97014 [electrical stimulation (unattended)]. This untimed code is not appropriate for dysphagia treatment if the SLP must be present to activate electrical stimulation at the appropriate moment. Incidentally, Medicare providers must convert this 97014 to G0283, "electrical stimulation, other than wound (unattended)." This code pays approximately $14.09.
Same-Day Billing (92526 + 97032)
Medicare correct coding initiative (CCI) edits allow 92526 and 97032 to be billed on the same day as an exception, to allow for situations in which a SLP renders dysphagia treatment on the same day that a physical therapist administers unrelated electrical stimulation to muscles.
In 2004, ASHA presented justification to CMS for billing CPT 92526 and CPT 97032 on the same day for dysphagia treatment. Some private health plans allow this pair to be billed on the same day, but CMS rejected the arguments; ASHA will continue to press the case that the two procedures can be billed appropriately on the same day.
To prevent retroactive denials one or two years later, providers should obtain written authorization for using both codes.
ASHA has developed "Questions to Ask When Evaluating Any Treatment Procedure, Product, or Program" to help clinicians evaluate available evidence and make informed decisions about clinical programs, products, or techniques.
For further information about coding and payment issues, contact Mark Kander, director of health care regulatory analysis, 800-498-2071, ext. 5669, or mkander@asha.org. For information regarding clinical issues, contact Amy Hasselkus, associate director of health care services in speech-language pathology, 800-498-2071, ext. 5686, or ahasselkus@asha.org.
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