Local Coverage Determination (LCD) for Home Health-Surface Electrical

Stimulation in the Treatment of Dysphagia (L31534)

 

 

Contractor Information

 

Contractor Name Palmetto GBA

 

Contractor Number 11004

 

Contractor Type HHH MAC

 

LCD Information

Document Information

 

LCD ID Number L31534

 

LCD Title Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia

 

Contractor's Determination Number J11HH-11-005-L

 

 

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2012 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.

 

Primary Geographic Jurisdiction Alabama Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi North Carolina             New Mexico Ohio Oklahoma South Carolina Tennessee Texas

 

 

Oversight Region Region IV

 

Original Determination Effective Date

For services performed on or after 01/24/2011 Original Determination Ending Date

 

Revision Effective Date

For services performed on or after 10/04/2012

 

Revision Ending Date

 

 

CMS National Coverage Policy

 

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

 

Indications and Limitations of Coverage and/or Medical Necessity

Surface electrical stimulation in the treatment of dysphagia is being used by some Medicare providers as an adjunct to “usual care”. There is insufficient scientific or clinical evidence to consider this device as reasonable and necessary for the treatment of dysphagia within the meaning of §1862(a)(1)(A) of the Social Security Act and will not be covered by this Intermediary.

 

 

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.

 

032x Home Health - Inpatient (plan of treatment under Part B only)

033x Home Health - Outpatient (plan of treatment under Part A, including DME under Part A)

 

 

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.

 

0420 Physical Therapy - General Classification 0421 Physical Therapy - Visit

0422 Physical Therapy - Hourly

0424 Physical Therapy - Evaluation or Re-evaluation 0429 Physical Therapy - Other Physical Therapy 0430 Occupational Therapy - General Classification 0431 Occupational Therapy - Visit

0432 Occupational Therapy - Hourly

0434 Occupational Therapy - Evaluation or Reevaluation 0439 Occupational Therapy - Other Occupational Therapy

0440 Speech Therapy - Language Pathology - General Classification 0441 Speech Therapy - Language Pathology - Visit

0449 Speech Therapy - Language Pathology - Other Speech Therapy

 

 

CPT/HCPCS Codes XX000 Not Applicable

 

 

ICD-9 Codes that Support Medical Necessity XX000 Not Applicable

 

 

Diagnoses that Support Medical Necessity

 

 

ICD-9 Codes that DO NOT Support Medical Necessity

 

787.20 DYSPHAGIA, UNSPECIFIED

787.21 DYSPHAGIA, ORAL PHASE

787.22 DYSPHAGIA, OROPHARYNGEAL PHASE

787.23 DYSPHAGIA, PHARYNGEAL PHASE

787.24 DYSPHAGIA, PHARYNGOESOPHAGEAL PHASE

787.29 OTHER DYSPHAGIA

 

 

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

 

Diagnoses that DO NOT Support Medical Necessity

 

 

General Information

 

Documentations Requirements

 

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the A/B MAC upon request.

 

Appendices N/A

 

Utilization Guidelines N/A

 

Sources of Information and Basis for Decision

 

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 January; 22(1): 1-10.

 

Shaw GY, Sechtem MS, Searl J et al. Transcutaneous Neuromuscular Electrical Stimulation (VitalStim) Curative Therapy for Severe Dysphagia: Myth or Reality? 01-JAN-2007; Annals of Otology, Rhinology & Laryngology.

116(1):36 – 44.

 

Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the Intermediary, this policy was developed in cooperation with advisory groups, which include representatives from the affected provider community. Advisory Committee

meeting date:

 

Start Date of Comment Period

 

End Date of Comment Period

 

Start Date of Notice Period 12/09/2010

 

Revision History Number Revision #1, 10/04/2012

 

Revision History Explanation Revision #1 effective 10/04/2012

Under Revenue Codes, deleted code 0443, this revenue code is for group therapy and is not applicable to home health. Under Documentation Requirements section changed the word ‘Intermediary’ to A/B MAC. This revision becomes effective 10/04/2012.

 

01/24/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Palmetto GBA Title 18 RHHI (00380) was removed from this LCD and implemented to Palmetto GBA J11 HH and H MAC (11004). Effective date of this Implementation is January 24, 2011.

 

Reason for Change Maintenance (annual review with new changes, formatting, etc.)

 

Related Documents

This LCD has no Related Documents.

 

LCD Attachments

There are no attachments for this LCD.

 

All Versions

Updated on 09/27/2012 with effective dates 10/04/2012 - N/A Updated on 11/30/2010 with effective dates 01/24/2011 - N/A