Coding Dysphagia
Coding dysphagia is dependent on the physician documentation in the medical record and the application of the Official Coding Guidelines for inpatient care.
Dysphagia constitutes a difficulty in swallowing, which may also be associated with pain. Occasionally, a patient may not be able to swallow at all. Although dysphagia can occur at any age, it is more common in older adults.
Dysphagia alone may not be of concern, but it may be indicative of a more serious condition requiring treatment if it persists or is severe. In addition, the condition may make it difficult for a patient to consume enough calories or fluids, which can lead to additional medical problems.
Since dysphagia is a symptom, it will not be sequenced as the principal diagnosis if the underlying cause has been documented by the physician. However, the appropriate code for dysphagia may be coded and sequenced as a secondary diagnosis if it is not inherent to the disease process.
Symptoms:
The following signs and symptoms are often associated with dysphagia:
- Pain while swallowing (odynophagia);
- Inability to swallow;
- Sensation of food stuck in throat or chest;
- Drooling;
- Hoarseness;
- Regurgitation;
- Frequent heartburn;
- Food or stomach acid backing up into throat;
- Unexpected weight loss; and
- Coughing, choking, or gagging while swallowing.
Causes:
The following are some common causes of oropharyngeal dysphagia:
- Postpolio syndrome
- Multiple sclerosis
- Muscular dystrophy
- Parkinson?s disease
- Cerebral palsy
- Stroke
- Brain or spinal cord injuries; and
- Esophageal diverticulum or Zenker?s diverticulum
Common causes of esophageal dysphagia are as follows:
? Achalasia
- Esophageal spasm
- Esophageal stricture
- Esophageal tumors;
- Gastroesophageal reflux disease
- Eosinophilic esophagitis and
- Systemic sclerosis
Complications:
Dysphagia can lead to the following complications:
- Malnutrition
- Dehydration and
- Aspiration pneumonia
Diagnosis:
To diagnose the underlying cause of the dysphagia, a physician may perform any of the following tests:
- Barium swallow or modified barium swallow;
- Endoscopy such as laryngoscopy or esophagoscopy;
- Endoscopic swallowing evaluation;
- Esophageal manometry; and
- Esophageal muscle test.
Treatment:
Treatment for dysphagia mainly depends on the type or the underlying cause. For oropharyngeal dysphagia, a speech therapist may teach a patient exercises to coordinate the swallowing muscles or teach swallowing techniques. Treatment for esophageal dysphagia may include esophageal dilation, surgery to remove esophageal tumor or diverticulum, or medication.
Severe dysphagia may require the insertion of a feeding tube or a percutaneous endoscopic gastrostomy tube.
Coding and sequencing for dysphagia are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care.
Coding for Dysphagia in ICD-10-CM:
Dysphagia is classified to ICD-10-CM subcategory R13.1, with a fifth character required as follows:
- R13.10, Dysphagia, unspecified (includes difficulty in swallowing, not otherwise specified);
- R13.11, Dysphagia, oral phase;
- R13.12, Dysphagia, oropharyngeal phase;
- R13.13, Dysphagia, pharyngeal phase;
- R13.14, Dysphagia, pharyngoesophageal phase; and
- R13.19, Other dysphagia, which includes cervical dysphagia and neurogenic dysphagia.
If the dysphagia is due to a prior stroke, then an appropriate code from category I69, Sequelae of cerebrovascular disease, with the final characters -91 is assigned and sequenced first followed by a code for the specific type of dysphagia (R13.10 to R13.19). For example, oropharyngeal dysphagia due to nontraumatic intracerebral hemorrhage is assigned to codes I69.191 and R13.12.
Dysphagia documented as functional, hysterical, nervous, or psychogenic is classified to code F45.8, Other somatoform disorders.
The coding guidelines for symptoms are the same in ICD-10-CM as they are in ICD-9-CM. In other words, a symptom code should not be sequenced as the principal diagnosis when a related definitive diagnosis has been established. Since dysphagia is a symptom, it will not be sequenced as the principal diagnosis if the underlying cause has been documented by the physician.