Dysphagia occurs when a patient has difficulty swallowing due to nerve or muscle problems in the throat or esophagus resulting from a stroke, gastroesophageal reflux disease (GERD), cancer of the throat or mouth and certain neurological disorders.
This condition is identified in Section R13, “Aphagia and Dysphagia,”of the ICD-10 classification set. But it isn’t enough for coders simply to report that a patient has unspecified dysphagia, R13.10.
Instead, they’ll need to select a code specifying the phase of swallowing that is specifically impaired. They may choose from:
Dysphagia, oral phase, R13.11
Dysphagia, oropharyngeal phase, R13.12
Dysphagia, pharyngeal phase, R13.13
Dysphagia, pharyngoesophageal, R13.14
Even with documentation specifying the phase of dysphagia which must be coded, this particular condition can create stumbling blocks to trip an unwary coder, so tread carefully.
Category R13.1 has a Type 1 Exclusion that can create issues. Exclusions are codes that should never be used at the same time as this code.
Tip: Be sure to review category R13.1’s exclusion before using this code for reimbursement purposes.