ICD-10 Coding for Dysphagia(R13.10, R13.11, R13.12, I69.391)
Complete ICD-10-CM coding and documentation guide for Dysphagia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dysphagia
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R13.10 | Dysphagia, unspecified | Use when the specific phase of dysphagia is not documented. |
|
| R13.11 | Dysphagia, oral phase | Use when documentation specifies oral phase dysphagia. |
|
| R13.12 | Dysphagia, oropharyngeal phase | Use when documentation specifies oropharyngeal phase dysphagia. |
|
| I69.391 | Dysphagia following cerebral infarction | Use when dysphagia is a sequela of 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
Essential facts and insights about Dysphagia
Primary ICD-10-CM Codes for dysphagia
Decision Criteria
documentation Criteria
- Lack of specific phase documentation.
Applicable To
- Difficulty swallowing
Excludes
- Dysphagia following a cerebrovascular accident (I69.3-)
Clinical Validation Requirements
- Clinical evaluation indicating swallowing difficulty without phase specification.
Code-Specific Risks
- May lead to denials if phase-specific information is available but not documented.
Coding Notes
- Ensure documentation supports the use of an unspecified code.
R13.11 - Dysphagia, oral phase
Use when documentation specifies oral phase dysphagia.
Applicable To
- Difficulty in the oral phase of swallowing
Excludes
- Dysphagia following a cerebrovascular accident (I69.3-)
Clinical Validation Requirements
- Clinical or instrumental evidence of oral phase impairment.
Coding Notes
Ensure documentation specifies oral phase involvement.
R13.12 - Dysphagia, oropharyngeal phase
Use when documentation specifies oropharyngeal phase dysphagia.
Applicable To
- Difficulty in the oropharyngeal phase of swallowing
Excludes
- Dysphagia following a cerebrovascular accident (I69.3-)
Clinical Validation Requirements
- Clinical or instrumental evidence of oropharyngeal phase impairment.
Coding Notes
Ensure documentation specifies oropharyngeal phase involvement.
I69.391 - Dysphagia following cerebral infarction
Use when dysphagia is a sequela of a stroke.
Applicable To
- Swallowing difficulty post-stroke
Clinical Validation Requirements
- History of cerebral infarction with documented dysphagia.
Coding Notes
Ensure stroke history is documented.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dysphagia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R13.10.
Impact
Clinical: May lead to inappropriate treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure phase-specific documentation is reviewed before coding., Educate clinicians on the importance of phase documentation.
Impact
Reimbursement: May lead to lower reimbursement due to lack of specificity., Compliance: Non-compliance with coding guidelines., Data Quality: Reduces data quality and specificity.
Mitigation Strategy
Document the specific phase of dysphagia whenever possible.
Impact
Lack of phase-specific documentation can lead to audit findings.
Mitigation Strategy
Implement training programs for clinicians on phase-specific documentation.
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, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dysphagia
Use these documentation templates to ensure complete and accurate documentation for Dysphagia. These templates include all required elements for proper coding and billing.
Acute care evaluation of dysphagia
Specialty: Speech-Language PathologyRequired Elements
- Phase-specific swallowing assessment
- Instrumental test results
- Dietary recommendations
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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