How To Use CPT Code 92616

CPT 92616 describes the flexible endoscopic evaluation of swallowing and laryngeal sensory testing using cine or video recording. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 92616?

CPT 92616 can be used to describe the evaluation of a patient’s pharynx and larynx to assess the health of the swallowing muscles and sensory deficits. This code is used when a provider uses a flexible endoscope and cine or video recording to perform the evaluation.

2. Official Description

The official description of CPT code 92616 is: ‘Flexible endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording.’

3. Procedure

1. The provider inserts a flexible endoscope through the nasal cavity into the lower pharynx.
2. The provider tests the muscles that aid in swallowing by administering air pulses of varying intensities to the inner lining of the lower pharynx.
3. The provider evaluates the sensory and motor deficits in the laryngeal muscles by observing the laryngeal reflex.
4. If the reflex is not triggered, the provider increases the intensity of the air pulses to elicit the reflex.
5. The provider records the patient’s airway protective reflexes and performs food administration trials if the reflex is intact.
6. The provider adjusts the endoscope during swallowing maneuvers to avoid aspiration or backward movement.
7. The provider may also bring the endoscope into the pharynx to assess the movement of administered food.

4. Qualifying circumstances

CPT 92616 is used for patients who require an evaluation of their swallowing function and laryngeal sensory testing. It is typically performed by a provider using a flexible endoscope and cine or video recording. This procedure should not be reported in conjunction with CPT code 31575.

5. When to use CPT code 92616

CPT code 92616 should be used when a provider performs a flexible endoscopic evaluation of swallowing and laryngeal sensory testing using cine or video recording. It is appropriate for patients who require an assessment of their swallowing function and laryngeal sensory deficits.

6. Documentation requirements

To support a claim for CPT 92616, the provider must document the following information:

• Patient’s symptoms or condition necessitating the evaluation
• Details of the flexible endoscopic evaluation, including the use of cine or video recording
• Date and duration of the procedure
• Findings from the evaluation, including any sensory or motor deficits observed
• Results of the food administration trials, if performed
• Any complications or adverse events
• Provider’s signature

7. Billing guidelines

When billing for CPT 92616, ensure that the procedure is performed using a flexible endoscope and cine or video recording. It should not be reported with CPT code 31575. Review all codes in the range 92612 to 92617 before selecting the appropriate code for an endoscopic swallowing evaluation.

8. Historical information

CPT 92616 was added to the Current Procedural Terminology system on January 1, 2003. It underwent code changes on January 1, 2010, and January 1, 2017.

9. Examples

1. A provider performs a flexible endoscopic evaluation of swallowing and laryngeal sensory testing using cine or video recording to assess a patient with dysphagia.
2. During the procedure, the provider observes sensory deficits in the laryngeal muscles of a patient with vocal cord paralysis.
3. A provider uses a flexible endoscope and cine or video recording to evaluate the swallowing function of a patient with a history of aspiration pneumonia.
4. Using the procedure, the provider identifies motor deficits in the swallowing muscles of a patient with Parkinson’s disease.
5. A provider performs a flexible endoscopic evaluation of swallowing and laryngeal sensory testing using cine or video recording to assess a patient with a suspected laryngeal sensory deficit.
6. During the procedure, the provider observes normal airway protective reflexes in a patient with no swallowing difficulties.
7. A provider uses a flexible endoscope and cine or video recording to evaluate the swallowing function of a patient with a history of head and neck cancer.
8. Using the procedure, the provider identifies sensory deficits in the laryngeal muscles of a patient with a history of radiation therapy.
9. A provider performs a flexible endoscopic evaluation of swallowing and laryngeal sensory testing using cine or video recording to assess a patient with chronic cough.
10. During the procedure, the provider observes motor deficits in the swallowing muscles of a patient with a history of stroke.