Question
Is esophageal dysphagia therapy reimbursable for Medicare in a Skilled Nursing Facility? If a resident is having chewing difficulty only, does this warrant a dysphagia evaluation, and is it paid for by Medicare? Where can I find out more about what is cov
Answer
The best resource to obtain information on what Medicare will reimburse for dysphagia can be obtained at one of two sites, either www.asha.org or www.cms.gov. Both websites offer a search function that will yield many excellent references with the search word of dysphagia. Section 450, Special Instructions for Billing Dysphagia, can be downloaded from the CMS website, and this document provides an overview of the services that are covered by Medicare, including long-term care.
Esophageal dysphagia (lower two thirds of the esophagus) is difficulty in passing food from the esophagus to the stomach. If peristalsis is inefficient, patients may complain of food getting stuck or of having more difficulty swallowing solids than liquids. Sometimes patients experience esophageal reflux or regurgitation if they lie down too soon after meals. SLPs are expected to have sufficient knowledge to assess the presence of esophageal dysphagia, including signs and symptoms as obtained in the assessment process and make an appropriate referral for proper follow-up. Esophageal dysphagia therapy is generally not reimbursable as swallowing therapy has not been of benefit for patients with esophageal dysphagia. The one exception to this would be the patient who has refused food/meals due to discomfort resulting from reflux. In this situation, the role of the SLP to establish a therapeutic feeding program in combination with medical management may be indicated and constitute reasonable and necessary care. This intervention would be very brief.
The presence of chewing difficulties may trigger an appropriate referral for a dysphagia assessment, particularly if this behavioral symptom is related to any in-coordination, sensation loss, or other neuromotor disturbances affecting oropharyngeal abilities. A reasonable and necessary assessment of function may be approved, even when the assessment determines that skilled intervention is not appropriate. The presence of a chewing difficulty in the absence of documented conditions consistent with CMS Special Billing Instructions may negate payment of the claim.
Sue Curfman, M.A., CCC, has been in the field of healthcare for 24 years with experience across the continuum of care including acute hospital, home health, outpatient and skilled nursing. She works as a Clinical Program Consultant with RehabCare Group. She holds a certificate in Case Management and Quality Management.
