ICD-10 Coding for Costovertebral Angle Tenderness with Dysphagia(I69.391, R10.819)
Complete ICD-10-CM coding and documentation guide for Costovertebral Angle Tenderness with Dysphagia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Costovertebral Angle Tenderness with Dysphagia
I69.3-I69.4Primary Range
Sequelae of cerebrovascular disease
Includes dysphagia following a cerebrovascular accident (CVA).
Symptoms and signs involving the digestive system and abdomen
Includes abdominal tenderness and dysphagia symptoms.
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 direct result of a previous stroke. |
|
| R10.819 | Abdominal tenderness, unspecified site | Use when CVA tenderness is present without a specific diagnosis. |
|
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 Costovertebral Angle Tenderness with Dysphagia
Primary ICD-10-CM Codes for costovertebral angle with dysphagia
Decision Criteria
clinical Criteria
- Confirmed history of stroke with documented dysphagia
documentation Criteria
- Swallow study results indicating dysphagia
Applicable To
- Dysphagia due to stroke
Excludes
- Dysphagia not related to stroke
Clinical Validation Requirements
- Documented history of cerebral infarction
- Swallow study confirming dysphagia
Code-Specific Risks
- Incorrectly coding dysphagia without linking to stroke
Coding Notes
- Ensure documentation clearly links dysphagia to the stroke event.
R10.819 - Abdominal tenderness, unspecified site
Use when CVA tenderness is present without a specific diagnosis.
Applicable To
- Costovertebral angle tenderness
Excludes
- Specific abdominal tenderness sites
Clinical Validation Requirements
- Physical examination showing CVA tenderness
- Imaging or lab results supporting renal pathology
Coding Notes
Document any associated renal conditions.
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 Costovertebral Angle Tenderness with Dysphagia 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: Potential audit issues, Financial: Reduced reimbursement
Mitigation Strategy
Use specific dysphagia phase codes, Ensure thorough documentation
Impact
Reimbursement: May result in lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Reduces accuracy of patient records.
Mitigation Strategy
Always document the specific phase of dysphagia and link it to the stroke.
Impact
Using unspecified codes without linking to stroke
Mitigation Strategy
Educate clinicians on the importance of specifying dysphagia phases.
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 Costovertebral Angle Tenderness with Dysphagia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Costovertebral Angle Tenderness with Dysphagia
Use these documentation templates to ensure complete and accurate documentation for Costovertebral Angle Tenderness with Dysphagia. These templates include all required elements for proper coding and billing.
Post-stroke dysphagia evaluation
Specialty: NeurologyRequired Elements
- History of stroke
- Swallow study results
- Phase of dysphagia
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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