ICD-10 Coding for Dysphagia Following Cerebrovascular Accident (CVA)(I69.391, R13.12)
Complete ICD-10-CM coding and documentation guide for Dysphagia Following Cerebrovascular Accident (CVA). Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dysphagia Following Cerebrovascular Accident (CVA)
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| I69.391 | Dysphagia following cerebral infarction | Use when dysphagia is a sequela of a past cerebral infarction. |
|
| R13.12 | Dysphagia, oropharyngeal phase | Use to specify the phase of dysphagia when linked to a stroke. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for dysphagia following stroke
Essential facts and insights about Dysphagia Following Cerebrovascular Accident (CVA)
Primary ICD-10-CM Codes for dysphagia following costovertebral angle
Decision Criteria
clinical Criteria
- Patient has a history of stroke with current dysphagia symptoms.
documentation Criteria
- Documentation explicitly links dysphagia to the stroke event.
Applicable To
- Dysphagia due to past ischemic stroke
Excludes
- Acute stroke (I63.9)
Clinical Validation Requirements
- History of ischemic stroke
- Current dysphagia symptoms
- Documentation linking dysphagia to stroke
Code-Specific Risks
- Incorrectly coding acute stroke instead of sequela
Coding Notes
- Always document the causal relationship between stroke and dysphagia.
R13.12 - Dysphagia, oropharyngeal phase
Use to specify the phase of dysphagia when linked to a stroke.
Applicable To
- Oropharyngeal dysphagia
Excludes
- Esophageal dysphagia (R13.14)
Clinical Validation Requirements
- Swallow study results indicating oropharyngeal phase impairment
Coding Notes
Ensure the phase of dysphagia is documented and coded correctly.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dysphagia Following Cerebrovascular Accident (CVA) to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I69.391.
Impact
Clinical: Inaccurate treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims.
Mitigation Strategy
Ensure swallow study results are included in documentation., Train staff on the importance of phase-specific coding.
Impact
Reimbursement: May lead to incorrect DRG assignment and reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Reduces specificity and accuracy of clinical data.
Mitigation Strategy
Always use a specific R13.1x code to indicate the phase.
Impact
Improper sequencing of I69.391 and R13.1x can lead to audit flags.
Mitigation Strategy
Train coders on proper sequencing rules.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Dysphagia Following Cerebrovascular Accident (CVA), with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dysphagia Following Cerebrovascular Accident (CVA)
Use these documentation templates to ensure complete and accurate documentation for Dysphagia Following Cerebrovascular Accident (CVA). These templates include all required elements for proper coding and billing.
Inpatient post-stroke dysphagia assessment
Specialty: NeurologyRequired Elements
- Stroke type and date
- Dysphagia phase
- Swallow study results
- Link between stroke and dysphagia
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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