Medicare Part B Supervision Requirements for Videostroboscopy and Nasopharyngoscopy Procedures

Effective October 1, 2011, there is no level of supervision designated in the Medicare Physician Fee Schedule database for videostrobscopy (CPT 31579) and nasopharyngoscopy (CPT 92511).

Frequently Asked Questions

These FAQs were developed in conjunction with Special Interest Group 3, Voice and Upper Airway Disorders. Please contact reimbursement@asha.org for further information.

• What does "no level of supervision" mean if I am an employee or contractor of a physician practice?
• Are there state laws that may supersede the Medicare rule regarding supervision of videostroboscopy and nasopharyngoscopy procedures?
• Can a regional Medicare Administrative Contractor (MAC) establish its own supervision requirement for these endoscopic procedures?
• Does the supervision rule apply to the fiberoptic endoscopic evaluation of swallowing (FEES) or fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) procedures?
• Can a physician separately bill for reviewing a stroboscopy or nasopharyngoscopy procedure that I have performed?
• Is an order/referral from a physician required?
• Are there Medicare rules for follow-up by a physician?
• What are the common methods for gaining the expertise to perform these procedures independently?
• Can I use topical anesthetics if a physician is not present?
• Medicare coverage of speech-language pathology services requires physician approval (or nurse practitioner, physician assistant or clinical nurse specialist) of a plan of care. If I do not provide follow-up treatment is there a document I can provide that is a substitute for a plan of care?
• If I wanted to independently bill Medicare for these procedures, how could I do it?

What does "no level of supervision" mean if I am an employee or contractor of a physician practice?

There is no distinction in the level of supervision assigned to a videostroboscopy or nasopharyngoscopy performed by an speech-language pathologist (SLP) whether the SLP is employed by a physician practice or if the SLP performs the procedure as an independent practitioner. That is, there is no requirement in current Medicare policy for physician supervision in either setting. However, state and/or Medicare Administrative Contractor (MAC) supervision requirements may supersede Medicare's requirement.

Are there state laws that may supersede the Medicare rule regarding supervision of videostroboscopy and nasopharyngoscopy procedures?

Some states have endoscopy laws/regulations specific to speech-language pathologists, including California, New Jersey, Illinois, Michigan, and Tennessee. Other states such as Maryland, New York, and Virginia have policy statements and/or guidance documents. In some cases, the licensure laws and regulations may refer only to fiberoptic endoscopic evaluation of swallowing (FEES) or to all forms of endoscopy. Call ASHA at 800-498-2071 and ask for a State Advocacy Team member for specific information regarding your state's requirements or go to ASHA's State-by-State webpages for contact information for your state's lincensure board or regulatory agency.

Can a regional Medicare Administrative Contractor (MAC) establish its own supervision requirement for these endoscopic procedures?

Yes. The lack of a national Medicare supervision indicator for these diagnostic procedures does not preclude the establishment of regional supervision designations under their authority to issue Local Coverage Determinations (LCDs). To find the appropriate LCD for your state, go to the Centers for Medicare & Medicaid Services (CMS) LCD by State Index webpage. At your chosen state, select the link labeled as MAC-Part B and, under LCDs, scroll to Speech-Language Pathology or Rehabilitation. If you do not find an active LCD for Speech-Language Pathology or Rehabilitation, or the language in the LCD does not address supervision requirements, then the MAC in your state has not issued a coverage determination on the topic and the national Medicare requirement (no designated level of supervision) stands.

Does the supervision rule apply to the fiberoptic endoscopic evaluation of swallowing (FEES) or fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) procedures?

No. Most regional MACs have determined the supervision level for FEES/FEESST in Local Coverage Determinations.

Can a physician separately bill for reviewing a stroboscopy or nasopharyngoscopy procedure that I have performed?

Unlike the fiberoptic endoscopic evaluation of swallowing (FEES) or fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) procedures, there is no separate code for "interpreting" the results of a videostroboscopy or nasopharyngosocopy. We think Medicare and most other payers would anticipate that the physician's effort in diagnosing a medical problem from the results of the stroboscopy or nasopharyngoscopy would be reflected in an office visit code. Although we have not seen a ruling to this effect, we suspect that if the physician repeats the videostrobosocopy or nasopharyngosocopy on the same day as one performed by his or her speech-language pathologist but for the purpose of performing a medical as opposed to a "functional" diagnosis, it would be considered duplicate billing and not reimbursed.

It is also possible that of two separate claims for the same code submitted by an independent speech-language pathologist and physician, payment could be determined based on the first claim to be processed.

Is an order/referral from a physician required?

Yes. The order may also be initiated by a nurse practitioner, physician assistant or clinical nurse specialist, if permitted under state law.

Are there Medicare rules for follow-up by a physician?

No, not specifically. However, as indicated in ASHA's Preferred Practice Patterns for the Profession of Speech-Language Pathology (Section 34: Voice Assessment), "All patients/clients with voice disorders are examined by a physician, preferably in a discipline appropriate to the presenting complaint."

What are the common methods for gaining the expertise to perform these procedures independently?

Speech-language pathologists can gain the knowledge, skills and competencies required to administer the procedure and interpret the results (and refer to a physician when appropriate) through a variety of means. This would include formal course work, mentorship, and methodology workshops. Several useful references include ASHA's Position Statement (2004), and Use of Endoscopy by Speech-Language Pathologists: Position Statement (2008). Please note that there is no ASHA knowledge & skills document for the nasopharyngoscopy procedure.

Can I use topical anesthetics if a physician is not present?

Many state licensure laws do not allow speech-language pathologists to use topical anesthetics. Other state laws or regulations may also specify the level of physician supervision related to such anesthetics. Call ASHA at 800-498-2071 and ask for a State Advocacy Team member for specific information regarding your state's requirements or go to ASHA's State-by-State webpages for contact information for your state's lincensure board or regulatory agency.

Medicare coverage of speech-language pathology services requires physician approval (or nurse practitioner, physician assistant or clinical nurse specialist) of a plan of care. If I do not provide follow-up treatment is there a document I can provide that is a substitute for a plan of care?

The Medicare Benefit Policy Manual states that documentation of a diagnostic procedure serves as the plan of care if it contains a diagnosis, or in those states where a therapist may not diagnose, a description of the condition. "The referral/order of a physician/NP/PA is the certification that the evaluation is needed and the patient is under the care of a physician." (Chapter 15, Section 220.3.C)

If I wanted to independently bill Medicare for these procedures, how could I do it?

Assuming you are enrolled in the Medicare program, you bill for these procedures on the 1500 claim form as you would other speech-language pathology services. If you have not enrolled in Medicare, you first need to submit an enrollment application to your regional Medicare Administrative Contractor. The electronic enrollment system (PECOS) is the most efficient way to apply. Go to ASHA's webpage for Medicare & Speech-Language Pathologists in Private Practice for more information on the enrollment process.