The Blog


I’m Theresa Richard. I’ve been a medical speech pathologist for 15+ years, I’m a Board Certified Specialist in Swallowing and Swallowing Disorders, and I’m incredibly passionate about evidence-based practice and equally considering patient preferences with clinical experience and research.

Let’s Be Social


How much is that Doggy in the Window? (The Step-by-Step Guide to Advocating for Access to Instrumentation Part 3)

by | Jul 15, 2017 | The Step-by-Step Guide to Advocating for Access to Instrumentation

Just send me the key points in a PDF download so I can figure this out already!



For some of us, having access to FEES or VFSS is like that puppy in the pet shop window that we always wanted, and our parents always said no, and we kicked and screamed the whole way home.

Except now we’re adults, and it’s at work, and we NEED it for our patients, and it’s the administrators that are telling us no.

And then one day you decided you were going to put together a plan and figure out exactly what that puppy costs, and what it needs, and you’re going to do all of the research so that Mommy and Daddy HAVE to say YES.

Except now you’re an adult, and it’s at work, and you NEED it for your patients, so you’re going to put together the most rock solid, evidence based, cost analysis for your administrator so that he/she HAS to say YES!

Ok, so if you’re just now joining us, you may want to revisit Part 1 about WHY we need instrumentals, and then in Part 2 you will learn about the costs in SNFs related to dysphagia and WHO else may be able to help you advocate.

So you may know why you want access to instrumentals, and deep down you know so desperately that you want (NEED) them, but you just have NO clue what it costs, or why the administrator keeps saying no,

So we’re going to start all the way back at square 1 here with how VFSS/FEES are paid for. You’re going to need to bring a strong case when you finally nail down a meeting with the administrator, Mr. Spendnomoney, and you want to be very well versed in how all of this works. I am going to use general ranges of prices that I’ve heard in recent years of doing mobile FEES in MY area, but in order to build the best case for YOUR facility, you’ll want to see if you can get access to the exact costs in your area.

So, If you work in a skilled nursing facility, the SNF has to abide by CMS (Centers for Medicare & Medicaid Services) Consolidating Billing Guidelines.

For Medicare Part A, which is what your patient will be if they have a qualifying 3 day hospital stay, can last up to 100 days, barring that the patient continues to make progress towards their prior level of functioning. The SNF receives a large sum of money from Medicare for accepting that Part A patient to help cover the costs of any testing they may need. In exchange for that lump sum, the SNF agrees to provide any and all diagnostic testing that is deemed necessary for that patient.

This is where some SNF administrators claim that they “don’t want to pay for the test.” It is true that the monies do come out of the SNFs pockets, but they only come out of the SNFs pockets that have already been lined by Medicare. If your administrator continues to say that they “can’t afford it,” you can print out and hand him/her this document, or you can call your local ombudsman (patient’s rights advocate), because by accepting that patient, they are agreeing to provide appropriate diagnostic testing.

Ok, so what exactly does a VFSS done at a local hospital cost the SNF for a MedA resident? The absolute cheapest I’ve found is $1,200, the most expensive I’ve found is $2,000, with about 90% of the facilities I service averaging around $1,500. (Again, this is in NY, your area may be different, don’t yell at me, I’m just sharing what I know.) It is important to note that it is not a flat rate either, there are a few different costs that add up to make that number, so it’s important to note that this number can fluctuate with fair market value.

Now, if you have a good Business Office Manager or CFO in your SNF, he/she will be able to pull up these numbers in a jiffy, however some CFOs have no idea what it costs, and that all of these factors go in to the total price, so that’s where you may have a little more homework to do.

Side note: Do NOT call the hospital and ask what the charge for an MBSS is. If they do know, they will only be able to tell you the CPT codes for the speech eval, they do not know all of the other moving parts involved that the SNF is responsible for paying under Consolidated Billing. (It’s like talking to giraffes about astronauts, you probably won’t get far.)

So, the costs that make up the price of a VFSS include:

  • The Speech VFSS CPT code, and possibly a Clinical Swallow Exam CPT code, and Speech Treatment CPT code
  • Radiology charges
  • Barium
  • Transportation
  • And a companion/aide if necessary.

Now each state (or geographic region) is governed by a MAC (Medicare Administrative Contractor). The MAC is responsible for setting the price that the hospital will charge the SNF for each CPT code. There are national and regional averages, but again if you can get your paws on the exact figure for each CPT code, your case will be much stronger when you present it to your administrator.

So let’s break down each segment here to give you an idea of the range in prices.

Speech VFSS CPT code – So there absolutely is the speech code for actual VFSS that gets billed, that CPT code is usually between $90-$110 depending on your area, however most hospitals also will charge for a clinical bedside swallowing exam and also a speech therapy treatment session to discuss results. Those can be around $100 each as well. Again, not all hospitals do this, but a fair amount do.

Radiology charges – There are a few different charges from radiology, and they usually include the cost to use the radiology suite, the cost for Radiologist to push the button, and also a radiology tech if there is one present. This can be the tricky number to track down, but most have reported around $400. Some hospitals will bill a radiology charge per patient, some bill the facility monthly, and some hospitals will bill the SNF ANNUALLY for all radiological procedures done at that hospital in the previous year. So if your administrator or billing person tells you that VFSS only costs a few hundred dollars, tell them to dig a little bit deeper in to the radiology bill. I’ve had a few facilities that had no idea that part of that annual radiology bill included portions of VFSSs, and when they started using a mobile company, all of a sudden that bill dropped significantly. (Viola! It’s magic!)

Barium – This cost used to be very minimal, however we had a major barium shortage a few years back and it’s a heck of a lot more expensive now than it used to be! This charge has increased significantly in recent years, and some hospitals are now charging the SNFs per patient.

Transportation – One of the main arguments I get for a facility not wanting to contract with a mobile service is “Oh we’re not far from the hospital, it’s right next door.” This may very well be a true statement, however, it is against CMS laws for the SNF to just wheel the resident over to the hospital, they have to be taken via medical transport. So either the facility hires a transportation service to drive the patient over which may require a companion or CNA to assist, or they have their own van to drive them, or in some really, really crappy SNFs, they will only agree to send the resident if the family transports them because they don’t want to foot that bill. (Hello illegal!) Want to figure out the cost of transportation and/or a companion on your own? Call the van service that pulls up to your SNF and ask them how much it costs to drive Larry over to the hospital, it may only be a few miles away, but you’ll be shocked at the sticker price.

FEES vs. MBSS costs

So that is how Part A operates.

Now Part B is a little bit different because:

  • The radiology portion can be directly billed from the hospital right to Medicare, so the cost to the SNF is about $400 less using our figures here.
  • And the SNF pays for 80% of the transportation costs (including companion costs), while the family pays 20%.

So there is a small cost to the family as well when ordering a VFSS at the hospital for a Part B patient.

Now, if you have an administrator that doesn’t believe that he/she pays for VFSS for Part Bs, they are usually only considering that radiology is billed directly, and they believe the family is responsible for 100% of the transportation. However, it’s important that they realize that there are also speech charges and 80% of transportation costs are in fact billed back to the SNF.

So in conclusion, (drumroll please…)

The cost to a SNF for a Part A patient to receive a VFSS is approximately $1,450.00 using all of my local figures. (Again, these are mine, don’t argue me, go figure out yours.)

If we take out the radiology charges and 20% of transportation for Part B, the SNF is still looking at approximately $900.

So now that you’ve been schooled in VFSS costs, whats the hype with the mobile MBS/FEES companies?

Well I cant speak for everyone, but I’ve heard anywhere from $250-$500 per mobile swallow study.

If we take a good easy number of $400 per study, the facility can save approximately $1,000 by using a mobile service for Part A, and about $600 for a Part B. Now as I stated above, the cost for all of the parts of a VFSS done at the hospital are all subject to change depending on market value for barium and transportation changes. The cost for a mobile MBSS/FEES is usually 1 flat rate. If you can call around to the mobile companies in your area and see how much they charge, you can compare that to your figures that you collected for MBSSs at the hospital and hopefully present a pretty powerful case for the cost effectiveness and convenience for a mobile company to contract with your facility. Don’t have a mobile company in your area? You should probably start one.

Side note: I also think I mentioned this is another post, but the contract that the SNFs sign with the mobile MBSS/FEES companies are essentially just pricing agreements. It’s illegal per CMS guidelines to be locked in to an exclusive contract with a diagnostic company. That way if you aren’t satisfied with the SLP doing the study, and you want to try a different company, or if you just want this specific patient to go back to the hospital for the VFSS, there is nothing stopping you from making that referral.

You are responsible for making the most clinically appropriate recommendation for your patient. This may be a good way to convince your administrator to sign a “contract” with a mobile company because it is essentially fee for service. You’re not satisfied? No biggie. No harm, no foul, no broken contracts, no non-competes allowed.

Another question that I usually get as soon as a fellow SLP brings up that they want to use a mobile swallow study service is: “Great! Can you bill insurance and Medicare just like all of our other vendors?” Nope, nope we can’t. Not for SNFs. For other settings, yes that is possible but as I stated above SNFs are subject to all CMS Consolidated Billing Regulations. Since VFSS/FEES fall under THERAPY codes, the SNF is responsible for them. It would be considered double dipping if the SNF bills Medicare for the 92612 FEES CPT code and then so did I.

Ok, hopefully you’re not totally fried after that massive brain dump, but now you may be one step closer to beginning to calculate how much exactly all of these various tests can cost, and with all of the research about WHY you need instrumentation, hopefully you can present a case to Mr. Spendnomoney that he does in fact need to spend some money, that his patients are legally entitled to 😉

Now, if I’ve got you so juiced up to go waltz in to Mr. Spendnomoney’s office tomorrow fully armed, click the green box at the top of this to download the PDF of ALL of the key points, sources, and sample scripts from the entire series. You’re welcome. Happy advocating!

If this entire post is completely greek to you, or if you would just like some additional support while trying to stay afloat on dysphagia island, please consider joining us for the Medical SLP Collective. We provide brand new weekly resources in the form of handouts and videos, a panel of experts to answer ALL of your Medical SLP questions (anonymously, and not limited to dysphagia) and monthly webinars for ASHA CEUs.