VitalCare Technology LLC
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Newsletter 11
Vital Topics from VitalCare
Small Sensor Placed On The Neck Records How A
Patient With Suspected Dysphagia Swallows
INSIDE THIS ISSUE:
Small Sensor Placed on the
Neck Records How a Patient
with Suspected Dysphagia
Swallows
1
Electrical Brain Stimulation
Alleviates Post-Stroke
Dysphagia
1
Bottom Line: Co-billing of
Cognitive, Dysphagia Codes
3
Those suffering from swallowing difficulties, especially stroke
patients, could be evaluated more efficiently and noninvasively
thanks to research under way at the University of Pittsburgh
and the University of Toronto.
Ervin Sejdic, assistant professor of electrical and computer
engineering in Pitt's Swanson School of Engineering, is
developing a small sensor that's externally placed on the neck
near the thyroid and records how a person swallows. The
primary author of a study on the sensor published online in
IEEE Transactions of Biomedical Engineering, Sejdic uses
simulation modeling to posit a mathematical solution to the low
diagnostic success rate of current swallowing tests.
Con’t. On page 2
Electrical Brain Stimulation
Alleviates Post-Stroke Dysphagia
After stroke, patients often suffer from dysphagia, a swallowing disorder that results in greater
healthcare costs and higher rates of complications such as dehydration, malnutrition, and
pneumonia. In a new study published in the July issue of Restorative Neurology and
Neuroscience, researchers have found that transcranial direct current stimulation (tDCS), which
applies weak electrical currents to the affected area of the brain, can enhance the outcome of
swallowing therapy for post-stroke dysphagia.
"Our pilot study demonstrated that ten daily sessions of tDCS over the affected esophageal
motor cortex of the brain hemisphere affected by the stroke, combined with swallowing training,
improved post-stroke dysphagia. We observed long-lasting effects of anodal tDCS over three
months," reports lead investigator Nam-Jong Paik, MD, PhD, of the Department of Rehabilitation
Medicine, Seoul National University College of Medicine, Seoul, South Korea.
Con’t. pg 4
Page 2
Vital Topics from VitalCare Technology
Small Sensor con’t.
Cont’.
"Unfortunately,
people eat or
drink something
10 to 20 times a
day," said
Sejdic. "And you
can't put a
person in front
of an x-ray that
many times, nor
does every
hospital have
the capability to
do so."
“We've seen a lot of patients, especially those suffering from strokes, die from
difficulty swallowing," said Sejdic. "This disorder, known medically as dysphagia,
can have dire consequences like malnutrition, dehydration, pneumonia, and even
death. Unfortunately, current methods are often cumbersome and not as effective
as they need to be."
In their paper, Sejdic and his University of Toronto collaborators suggest a
mathematical algorithm that works electronically "behind the scenes" to improve the
images captured by his neck sensor, which is the size of a quarter and affixed using
double-sided tape. He and his team tested the model sensor on 40 dysphagic
patients, who were instructed to take several sips of liquid in a head-neutral
position. The result was a 90 percent success rate in diagnosing dysphagia.
Today's dysphagia evaluations make use of videofluoroscopy exams - motion xrays prescribed by speech-language pathologists - that take snapshots of the throat,
said Sejdic. These exams are effective at tracking whether food is going into one's
airway instead of the stomach (aspiration); which parts of the mouth and throat may
not be working well; and whether certain positions or strategies help a person
swallow better.
"Unfortunately, people eat or drink something 10 to 20 times a day," said Sejdic.
"And you can't put a person in front of an x-ray that many times, nor does every
hospital have the capability to do so."
For stroke patients rushed into the hospital, an even more basic exam is
administered. This includes simple water tests in which patients drink a glass of
water and are evaluated on whether they cough or have "wet voice" (a condition
where it sounds like patients are producing words through moisture). However,
those tests show an even lower level of efficacy.
"These simple tests have a success rate below 50 percent," said Sejdic. "You're
better off flipping a coin."
Sejdic and his colleagues have been working on their model sensor for almost three
years, and negotiations are under way for a clinical trial in the United States and
Canada. While the researchers' neck sensor could help all patients with dysphagia,
they are specifically targeting stroke sufferers, as this occurs in 37 to 78 percent of
those patients.
University of Pittsburgh. "Small Sensor Placed On The Neck Records How A Patient With
Suspected Dysphagia Swallows." Medical News Today. MediLexicon, Intl., 29 Mar. 2013.
Web.
4 May. 2013. <http://www.medicalnewstoday.com/releases/258281.php>
Vital Topics from VitalCare Technology
Page 3
Bottom Line: Co-Billing of Cognitive, Dysphagia Codes
By Janet Brown & Lisa Satterfield
Speech-language pathologists may bill for cognitive skills treatment and treatment for
swallowing disorders provided to the same Medicare patient on the same day,
according to a clarification from the Centers for Medicare and Medicaid Services
(CMS).
In a letter, ASHA had requested that CMS reconsider language in the National Correct
Coding Initiative (NCCI) Policy Manual regarding treatment of dysphagia and
cognitive disorders provided and billed to the same patient on the same day. The policy
manual outlines which procedures may not be billed together for the same patient.
The procedures delineated in ASHA's letter included the following CPT (Current
Procedural Terminology, © American Medical Association) codes:


97532: Development of cognitive skills to improve attention, memory, problem
solving (includes compensatory training), direct (one-on-one) patient contact
by the provider, each 15 minutes.
92526: Treatment of swallowing dysfunction and/or oral function for feeding.
CMS responded to the letter, stating "...if an SLP separately performs the services
described by CPT code 97532 entirely unrelated to the services described by CPT code
92526, the services may be reported separately." For these cases, the modifier -59
would be added to CPT code 97532.
This interpretation represents a shift from previous explanations that indicated 97532
could not be billed in combination with swallowing treatment codes on the same day.
The letter from CMS maintains that the codes may be billed together only for patients
who have two distinct plans of care for dysphagia and cognitive impairments,
indicating it would be most efficient to treat both disorders on the same day.
Providers should bill CPT 97532 only when cognitive treatment is truly a distinct,
separate activity. SLPs should not bill cognitive treatment when they provide only
swallowing or language treatment to a patient who also has cognitive disorders.
However, it may be appropriate to bill 97532 on the same day if there are distinct plans
of care and specific goals and treatment activities for cognitive impairment and for
swallowing.
For example, working on swallowing with a patient with mild dementia would not
warrant use of 97532 in addition to 92526. In contrast, working on separate dysphagia
and attention goals for a patient with TBI could be billed as 97532 and 92526. Clear
documentation of distinctive treatment is necessary when a single provider includes
97532 with other speech-language treatment codes on the same day to the same patient.
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Page 4
Vital Topics from VitalCare Technology
Electrical Brain Stimulation con’t.
Sixteen patients with acute post-stroke dysphagia were enrolled in the trial. They showed signs of
swallowing difficulties such as reduced tongue movements, coughing and choking during eating, and vocal
cord palsy. Patients underwent ten 30-minute sessions of swallowing therapy and were randomly assigned
to a treatment or control group. Both groups were fitted with an electrode on the scalp, on the side of the
brain affected by the stroke, and in the region associated with swallowing. For the first 20 minutes of their
sessions, tDCS was administered to the treatment group and then swallowing training alone continued for
the remaining 10 minutes. In the control group, the direct current was tapered down and turned off after
thirty seconds. Outcomes were measured before the experiment, just after the experiment, and again three
months after the experiment. A patient from each group underwent a PET scan at before and just after the
treatment to view the effect of the treatment on metabolism.
All patients underwent interventions without any discomfort or fatigue. There were no significant
differences in age, sex, stroke lesion site, or extent of brain damage. Evaluation just after the conclusion of
the sessions found that dysphagia improved for all patients, without much difference between the two
groups. However, at the three month follow-up, the treatment group showed significantly greater
improvement than the control group.
In the PET study, there were significant differences in cerebral metabolism between the first PET scan and
the second PET scan in the patient who had received tDCS. Increased glucose metabolism was observed in
the unaffected hemisphere, although tDCS was only applied to the affected hemisphere, indicating that
tDCS might activate a large area of the cortical network engaged in swallowing recovery rather than just
the areas stimulated under the electrode.
"The results indicate that tDCS can enhance the outcome of swallowing therapy in post-stroke dysphagia,"
notes Dr. Paik. "As is always the case in exploratory research, further investigation involving a greater
number of patients is needed to confirm our results. It will be important to determine the optimal intensity
and duration of the treatment to maximize the long-term benefits."
From: Advance
Posted on: September 10, 2012
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