ICD-10 Coding for Subglottic Stenosis(J38.6, J95.5, Q31.1)
Complete ICD-10-CM coding and documentation guide for Subglottic Stenosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Subglottic Stenosis
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| J38.6 | Acquired subglottic stenosis | Use for acquired stenosis without iatrogenic cause. |
|
| J95.5 | Postprocedural subglottic stenosis | Use when stenosis is directly related to a medical procedure. |
|
| Q31.1 | Congenital subglottic stenosis | Use for congenital cases confirmed by neonatal history. |
|
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 acquired subglottic stenosis
Essential facts and insights about Subglottic Stenosis
Primary ICD-10-CM Codes for subglottic stenosis
Decision Criteria
clinical Criteria
- No history of intubation or tracheostomy
Applicable To
- Idiopathic subglottic stenosis
Excludes
- Congenital subglottic stenosis (Q31.1)
Clinical Validation Requirements
- Endoscopic confirmation of subglottic narrowing
- Absence of prior intubation or tracheostomy
Code-Specific Risks
- Misclassification if iatrogenic cause is present
Coding Notes
- Ensure documentation specifies acquired nature and excludes iatrogenic causes.
J95.5 - Postprocedural subglottic stenosis
Use when stenosis is directly related to a medical procedure.
Applicable To
- Stenosis due to intubation
- Stenosis due to tracheostomy
Excludes
- Acquired subglottic stenosis (J38.6)
Clinical Validation Requirements
- History of intubation or tracheostomy
- Endoscopic confirmation of stenosis
Coding Notes
Document the procedure leading to stenosis clearly.
Q31.1 - Congenital subglottic stenosis
Use for congenital cases confirmed by neonatal history.
Applicable To
- Congenital narrowing of the subglottic region
Excludes
- Acquired subglottic stenosis (J38.6)
Clinical Validation Requirements
- Symptoms present since birth
- Confirmed via neonatal records
Coding Notes
Ensure congenital nature is documented.
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 Subglottic Stenosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code J38.6.
Impact
Clinical: Misleading clinical records, Regulatory: Potential audit issues, Financial: Denied claims
Mitigation Strategy
Review patient history thoroughly, Ensure procedural details are included
Impact
Reimbursement: Incorrect DRG assignment, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate clinical data
Mitigation Strategy
Use J95.5 for postprocedural stenosis.
Impact
Using J38.6 for iatrogenic cases can lead to audits.
Mitigation Strategy
Verify procedural history before coding.
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 Subglottic Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Subglottic Stenosis
Use these documentation templates to ensure complete and accurate documentation for Subglottic Stenosis. These templates include all required elements for proper coding and billing.
Post-intubation stenosis
Specialty: OtolaryngologyRequired Elements
- Procedure history
- Endoscopic findings
- Symptom description
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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