CPT Code Guide · April 2026

CPT 92610: Clinical Swallowing Evaluation Billing Guide for SLPs

CPT 92610 covers the clinical (bedside) evaluation of oral and pharyngeal swallowing function — one of the most important assessment services SLPs provide. For independent SLPs who see patients with dysphagia, getting this code right means accurate reimbursement and clean claims. Getting it wrong can mean denials, recoupments, and audit exposure.

What 92610 Covers

CPT 92610 is defined as the evaluation of oral and pharyngeal swallowing function. This is the clinical swallowing evaluation — performed without instrumental assessment (no fluoroscopy, no endoscopy). It typically includes:

• Review of the patient's medical history as it relates to swallowing function
• Cranial nerve examination relevant to swallowing (CN V, VII, IX, X, XII)
• Oral mechanism examination — strength, range of motion, coordination, sensation, and structural integrity of oral structures
• Trial swallows using various food and liquid consistencies
• Observation of swallowing physiology — oral preparatory, oral transit, pharyngeal, and where clinically observable, esophageal phases
• Assessment of airway protection — cough reflex, vocal quality changes, signs of aspiration or penetration
• Clinical judgment regarding swallowing safety and efficiency

92610 vs. 92611: Know the Difference

The most important billing distinction in dysphagia evaluation is between 92610 (clinical/bedside) and 92611 (instrumental/fluoroscopic):

• 92610 — Clinical evaluation. No imaging. Based on direct observation, patient history, and clinical judgment.
• 92611 — Fluoroscopic evaluation (MBSS/VFSS). Requires radiologic imaging with recorded video. Performed in a radiology suite.

These are not hierarchical codes — 92610 is not a "lower level" of 92611. They describe fundamentally different procedures. An SLP who performs a bedside swallow eval bills 92610. An SLP who performs a Modified Barium Swallow Study bills 92611. Both can be billed on the same date of service if both are performed and documented as distinct evaluations.

Documentation Requirements

CMS guidance indicates that 92610 documentation should include:

• Reason for referral — the clinical indication for the swallowing evaluation (stroke, head/neck surgery, neurological condition, aspiration pneumonia history, etc.)
• Oral mechanism examination findings — specific findings regarding lingual strength, labial seal, palatal function, dentition, and oral sensation
• Trial swallow details — each consistency trialed (thin liquid, nectar-thick, puree, solids), the volume presented, and specific patient response to each trial
• Signs and symptoms observed — coughing, throat clearing, wet vocal quality, delayed swallow initiation, oral residue, nasal regurgitation — documented specifically, not generically
• Clinical impression — your professional assessment of the patient's swallowing safety and efficiency based on the clinical findings
• Recommendations — diet texture recommendations, compensatory strategies, need for instrumental assessment, treatment plan, and/or referrals

The most common documentation failure: writing "patient tolerated PO trials without signs of aspiration" without specifying which consistencies were trialed, what volumes were used, or what specific observations were made. This level of vagueness does not support a comprehensive evaluation code.

Modifier Requirements

When billing 92610 to Medicare Part B:

• -GN modifier — Required. Identifies the service as delivered under an SLP plan of care.
• -KX modifier — Required if the patient is above the therapy cap threshold (dysphagia evaluation charges count toward the PT/SLP combined cap).
• -59 or XE modifier — May be needed if billing 92610 alongside 92507 on the same date of service to bypass NCCI edit pairs.

Billing 92610 and 92507 on the Same Date

It's clinically common to perform a swallowing evaluation and provide treatment in the same visit. CMS allows billing both 92610 and 92507 on the same date of service, but there are NCCI edit pair considerations. Best practice suggests:

• Document the evaluation and treatment as clearly separate services with distinct start/stop times
• The evaluation should be complete before treatment begins — don't blend evaluation activities into the treatment note
• Use modifier -59 or XE on the treatment code if your clearinghouse or MAC requires it to bypass the NCCI edit
• Some MACs do not allow same-day evaluation and treatment — check your local coverage determination

Telehealth and 92610

Clinical swallowing evaluations present unique challenges for telehealth delivery. CMS guidance generally does not support billing 92610 for a telehealth encounter because the code requires direct observation of swallowing function, including trial swallows — activities that carry aspiration risk and typically require the clinician to be physically present.

Some MACs have made exceptions under specific circumstances (e.g., a trained facilitator present with the patient while the SLP observes via video), but this is not universally accepted. Best practice suggests checking your MAC's current telehealth policy before scheduling telehealth dysphagia evaluations.