ICD-10 Coding for Oral Dysphagia(R13.11)
Complete ICD-10-CM coding and documentation guide for Oral Dysphagia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Oral Dysphagia
R13.1Primary Range
Dysphagia
This range includes all types of dysphagia, with R13.11 specifically for oral phase dysphagia.
Key Information: ICD-10 code for oral dysphagia
Essential facts and insights about Oral Dysphagia
Primary ICD-10-CM Code for oral dysphagia
Decision Criteria
clinical Criteria
- Presence of oral phase swallowing difficulty confirmed by VFSS or FEES.
documentation Criteria
- Detailed description of oral phase impairment, such as bolus formation issues.
Applicable To
- Difficulty initiating swallow
- Lingual pumping observed
Clinical Validation Requirements
- Videofluoroscopic Swallow Study (VFSS) showing oral residue >10%
- Fiberoptic Endoscopic Evaluation of Swallowing (FEES) revealing delayed oral transit
Code-Specific Risks
- Incorrectly coding as unspecified dysphagia (R13.10) when oral phase is documented.
Coding Notes
- Ensure documentation specifies the oral phase to avoid using unspecified codes.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Dysphagia following cerebral infarction
I69.191Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Oral Dysphagia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R13.11.
Impact
Clinical: Inaccurate treatment planning., Regulatory: Potential audit issues., Financial: Denied claims due to insufficient documentation.
Mitigation Strategy
Use specific phase-related terminology., Include objective findings from swallow studies.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use R13.11 when documentation specifies oral phase dysphagia.
Impact
Lack of specific phase documentation can lead to audit flags.
Mitigation Strategy
Ensure detailed documentation of oral phase findings.
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 Oral Dysphagia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Oral Dysphagia
Use these documentation templates to ensure complete and accurate documentation for Oral Dysphagia. These templates include all required elements for proper coding and billing.
Acute care setting for stroke patient
Specialty: Speech-Language PathologyRequired Elements
- Oral mechanism exam findings
- Clinical swallow findings
- Plan of care
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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