ICD-10 Coding for Dysphagia due to Cerebrovascular Accident (CVA)(I69.391, R13.12)
Complete ICD-10-CM coding and documentation guide for Dysphagia due to 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 due to Cerebrovascular Accident (CVA)
I69.3-I69.9Primary Range
Sequelae of cerebrovascular disease
This range includes codes for conditions resulting from previous cerebrovascular accidents, such as dysphagia.
Dysphagia
This range includes codes for different types of dysphagia, which are used in conjunction with sequelae codes.
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 residual effect of a past cerebral infarction. |
|
| R13.12 | Oropharyngeal dysphagia | Use to specify the type of dysphagia when linked to a sequelae of CVA code. |
|
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 due to CVA
Essential facts and insights about Dysphagia due to Cerebrovascular Accident (CVA)
Primary ICD-10-CM Codes for dysphagia due to costovertebral angle
Decision Criteria
clinical Criteria
- Presence of dysphagia symptoms post-CVA
documentation Criteria
- Explicit documentation linking dysphagia to CVA
Applicable To
- Oropharyngeal dysphagia due to past stroke
Excludes
- Acute cerebrovascular accident (I63.9)
Clinical Validation Requirements
- MRI/CT showing old infarct
- Neurology note linking dysphagia to CVA
Code-Specific Risks
- Incorrectly coding without linking to past CVA
Coding Notes
- Ensure documentation explicitly links dysphagia to the past CVA.
R13.12 - Oropharyngeal dysphagia
Use to specify the type of dysphagia when linked to a sequelae of CVA code.
Applicable To
- Difficulty swallowing due to pharyngeal phase issues
Excludes
- Aphagia (R13.0)
Clinical Validation Requirements
- FEES/VFSS report detailing pharyngeal residue
Coding Notes
Ensure the type of dysphagia is documented clearly.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dysphagia due to 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: May lead to inappropriate treatment., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims.
Mitigation Strategy
Ensure detailed documentation linking dysphagia to CVA.
Impact
Reimbursement: May lead to incorrect DRG assignment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate representation of patient's condition.
Mitigation Strategy
Add I69.391 as the primary code.
Impact
Claims without FEES/MBS or neurology correlation.
Mitigation Strategy
Ensure all claims are supported by appropriate clinical 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 due to Cerebrovascular Accident (CVA), with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dysphagia due to Cerebrovascular Accident (CVA)
Use these documentation templates to ensure complete and accurate documentation for Dysphagia due to Cerebrovascular Accident (CVA). These templates include all required elements for proper coding and billing.
Acute Care Setting
Specialty: NeurologyRequired Elements
- History of Present Illness
- Physical Exam
- Assessment
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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