2025 CPT code 92616
(Active) Effective Date: N/A Revision Date: N/A Medicine - Evaluative and Therapeutic Otorhinolaryngologic Services Special Otorhinolaryngologic Services and Procedures Feed
Flexible endoscopic evaluation of swallowing and laryngeal sensory testing using cine or video recording.
Modifiers may be applicable depending on the circumstances of the service.Refer to the CPT manual and payer-specific guidelines for the appropriate modifier use.
Medical necessity for 92616 is established when a patient presents with symptoms suggestive of dysphagia, including difficulty swallowing, choking, coughing during meals, weight loss, or aspiration pneumonia.The procedure is medically necessary to evaluate the swallowing mechanism and laryngeal reflexes, identify the etiology of symptoms, guide appropriate management decisions, and prevent potential complications such as aspiration pneumonia.
The otolaryngologist or other qualified healthcare professional performs the endoscopic examination, assesses the swallowing mechanism and laryngeal reflexes, and interprets the findings to diagnose and manage swallowing disorders.
- Special Otorhinolaryngologic Services and Procedures
- Medicine Services and Procedures > Special Otorhinolaryngologic Services and Procedures
In simple words: The doctor uses a thin, flexible tube with a camera on the end to look at the patient's throat and voice box to check how well they swallow and if their throat reflexes work correctly.The examination is recorded on video to help the doctor understand the findings and is used to assess swallowing and the protective reflexes that prevent food from going into the lungs.
This CPT code encompasses a comprehensive flexible endoscopic evaluation of swallowing function and laryngeal sensory testing, employing cine or video recording for documentation.The procedure involves passing a flexible endoscope through the nasal cavity into the lower pharynx to assess pharyngeal muscle health and swallowing mechanics. Laryngeal sensory testing evaluates the sensory and motor function of the laryngeal muscles via controlled air pulses to elicit laryngeal reflexes. The intensity of these pulses is adjusted to determine the threshold for triggering the reflex.Video or cine recording is essential for detailed analysis of the findings. Food administration trials may be included to further evaluate swallowing safety and efficiency. The entire procedure is meticulously documented to provide a complete assessment of the patient's swallowing mechanism and airway protection.
Example 1: A patient presents with dysphagia (difficulty swallowing) following a stroke.A flexible endoscopic evaluation of swallowing (FEES) with laryngeal sensory testing is performed using cine or video recording to assess pharyngeal function and identify any aspiration risks.The procedure reveals decreased pharyngeal contraction and delayed triggering of the laryngeal reflex, guiding management decisions regarding dietary modifications and therapeutic interventions., A patient with suspected laryngeal sensory deficits after a head injury undergoes 92616.The FEES study shows significantly reduced or absent laryngeal reflexes, indicating a compromised airway protective mechanism. This information is crucial for developing strategies to prevent aspiration pneumonia and tailoring appropriate interventions., A patient with Parkinson's disease experiences intermittent choking episodes during mealtimes.92616 is performed to evaluate the underlying swallowing dysfunction. The video recording helps to visualize the pharyngeal and laryngeal movements during swallowing, identifying the specific points of impairment, informing targeted therapy including compensatory swallowing techniques or other intervention strategies.
* Detailed patient history including symptoms, relevant medical history, and prior therapies.* Thorough clinical examination notes, focusing on findings relevant to swallowing and airway protection.* Comprehensive description of the procedure performed, including equipment used, visual findings, and quantified measures of laryngeal sensory thresholds.* Cine or video recording of the entire procedure.* Post-procedure assessment of patient condition and plans for further management.* Supporting documentation to substantiate medical necessity.
** Accurate documentation and coding of 92616 are crucial for appropriate reimbursement and appropriate medical care.Any deviations from standard procedures must be clearly documented to justify coding decisions.
- Revenue Code: P8I (ENDOSCOPY - OTHER)
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Otolaryngology, Speech-Language Pathology, Gastroenterology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center