ASHA Talking Points on SLPs Performing Endoscopy for Swallowing Assessment
What is ASHA's position on SLPs performing endoscopy for swallowing assessment (i.e., FEES)?
The use of endoscopy by SLPs is specifically included in ASHA's 2007 Scope of Practice (see Clinical Services, example 9). ASHA's Code of Ethics addresses the issue of competence generically in Principle of Ethics II, Rule B, which states that SLPs may only practice in areas "...that are within the scope of their competence, considering their level of education, training, and experience." ASHA has approved the following practice policy documents on the use of endoscopy by SLPs for the assessment of swallowing:
(Note: These documents may be found in the ASHA Practice Policy section of the Web site.)
What is the position of state licensing boards on SLPs performing endoscopy?
Some states specifically include endoscopy in the speech-language pathology scope of practice either by law or by regulation. For example, Missouri has a clear definition in statute, which was achieved by amending the scope of practice in 1998 to include:
"(f) uses instrumental technology to diagnose and treat disorders of communication and swallowing, such as videofluoroscopy, nasendoscopy, ultrasonography and stroboscopy."
More recently, licensure laws in California (2002), New Jersey (2005), and Tennessee (2007) have been amended to include specific language about SLPs using endoscopy to evaluate swallowing disorders. The Tennessee law states the following:
"The practice of speech-language pathology shall include the use of rigid and flexible endoscopes to observe the pharyngeal and laryngeal areas of the throat in order to observe, collect data, and measure the parameters of communication and swallowing for the purpose of functional assessment and rehabilitation planning."
-Senate Bill No. 1168, Section 1(B)
The bill goes on to specify conditions the SLP must meet to be able to use an endoscope. The Calfornia bill contains similar language and conditions. New Jersey was able to advocate for a change in the licensure law that previously banned the use of endoscopes by SLPs.
In other states, licensing boards have interpreted more general statutory language to mean that endoscopy is within the scope of practice of the speech-language pathologist. For example, New York has indicated that endoscopy is within the scope of SLPs' practice if they assume responsibility for its risks and do not administer any anesthesia.
A few states have ruled that endoscopy is a medical procedure and not within the SLP's scope of practice. Many states have no formal position on this issue.
What CPT codes can be used for endoscopic swallowing assessments?
In 2002, the American Medical Association (AMA), in collaboration with professional associations such as ASHA and AAO-HNS, approved CPT codes for endoscopic swallowing assessments, effective 2003. These codes replaced "G" codes established by Medicare in 2001.
The CPT codes that apply to endoscopic evaluation of swallowing are:
92612 Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording [FEES] (formerly GO193)
92613 Physician interpretation and report only (of above procedure)
92616 Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording [e.g., FEESST] (replaces GO193 and GO194 combination)
92617 Physician interpretation and report only (of above procedure)
The Medicare Fee Schedule includes current payment rates for these codes.
In determining reimbursement rates in 2003, the Centers for Medicare and Medicaid Services (CMS) stated that: "The interpretation of this test is an integral part of the testing itself. If a nonphysician professional has the credentials and experience to perform this testing, then that professional should also provide the interpretation of the findings." [ Federal Register (December 31, 2002, v.67 (251) p. 80010.] CMS has interpreted the activity in code 92613 and 92617 as essentially duplicating the function performed in 92612 and 92616, and therefore determined not to reimburse two providers for performing the same function. In 2004 reimbursement rates for physician interpretation and report associated with FEES and FEEST were again added to the Fee Schedule.
In addition, otolaryngologists who perform a medical diagnosis while collaborating with SLPs who perform the functional swallowing aspects of the procedure may consider using other codes to reflect the medical portion of the examination.
What is ASHA's response to the March 2003 position statement of the Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) on "Fiberoptic Endoscopic Examinations of Swallowing" that states that otolaryngologists or other physicians should "directly supervise" non-physician professionals who perform this procedure?
On April 21, 2003, AAO-HNS's President and Executive Vice President sent a letter to ASHA's Executive Director to notify him of their March 2003 position statement. They stated that this supersedes any previous statement. The new statement contradicts the 1999 joint ASHA/AAO-HNS statement on Roles of speech-language pathologists and otolaryngologists performing endoscopic examinations of swallowing, even though there have been no published data or anecdotal reports that challenge the safety or value of SLPs performing these studies for functional assessment of swallowing problems.
The AAO-HNS shift in position between 1999 and 2003 is unexpected, especially in light of the 1999 AAO-HNS preface: "Much research, thought, and negotiation went into the statement, which has been approved by both organizations." The AAO-HNS changes in wording are itemized below:
1999: " SLPs with specialized training are qualified to use FEES for assessment of swallowing function. Physicians use fiberoptic endoscopic examinations to render medical diagnoses."
2003: " Physicians are the only professionals qualified and licensed to render medical diagnoses related to the pathology affecting swallowing functions...Consequently; examinations should be viewed and interpreted by an otolaryngologist or other physician with training in this procedure."..."In addition, otolaryngologists or other physicians with training in this procedure should directly supervise non-physician professionals who are performing this procedure."
In 2005, ASHA issued a revised position statement that supports the SLPs' independent role in performing endoscopic evaluations of swallowing.
According to Medicare, do SLPs have to be directly supervised by a physician when performing endoscopy?
Medicare fiscal intermediaries may determine the settings in which they will reimburse the facility when the study is performed by a speech-language pathologist. There are some Local Medical Review Policies (LMRPs) that restrict payment to settings where a physician is available in the office suite. Many of these LMRPs also include wording indicating that in a hospital setting, the physician supervision requirement is presumed to be met and need not be documented. "Direct supervision" is used by Medicare to mean that the physician needs to be available in case assistance is needed, but "personal supervision" is not required by Medicare for these procedures.
How do I respond to physicians who, as a result of the new AAO/HNS position, insist upon supervising and billing for the endoscopic procedure?
You can show them the ASHA position statement and assure them that your role is to provide a functional diagnosis of swallowing, not a medical diagnosis. If you have been performing fiberoptic endoscopic assessments of swallowing, there are no new policies from your professional association (ASHA), your state licensing board, or Medicare that would force you to discontinue that practice. (Keep in mind that some local Medicare review policies require that a physician must be accessible in the office suite/examination area.)
SLPs who perform a functional assessment of swallowing typically administer a series of boluses with a variety of food and liquid textures and compensatory strategies. These components are essential to making recommendations for appropriate diet, maneuvers, and positioning in order to maximize the patient's safety and nutritional intake, and are different from a medical assessment. Let the physician know that the time involved in performing a functional swallowing assessment is likely to be much greater than for a medical assessment, for the reasons described above.