ICD-10 Coding for Trouble Swallowing(R13.11, R13.12, R13.14)
Complete ICD-10-CM coding and documentation guide for Trouble Swallowing. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Trouble Swallowing
R13.1Primary Range
Dysphagia
This range covers all types of dysphagia, including oral, pharyngeal, and esophageal phases.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R13.11 | Dysphagia, oral phase | Use when the patient exhibits oral phase dysphagia symptoms such as impaired tongue propulsion. |
|
| R13.12 | Dysphagia, oropharyngeal phase | Use when the patient has oropharyngeal phase dysphagia symptoms. |
|
| R13.14 | Dysphagia, pharyngoesophageal phase | Use when the patient has pharyngoesophageal phase dysphagia symptoms. |
|
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 trouble swallowing
Essential facts and insights about Trouble Swallowing
Primary ICD-10-CM Codes for trouble swallowing
Decision Criteria
clinical Criteria
- Presence of oral phase symptoms like tongue coordination issues.
Applicable To
- Impaired bolus formation
- Tongue coordination issues
Excludes
- Oropharyngeal dysphagia (R13.12)
Clinical Validation Requirements
- Documented oral residue
- Ineffective mastication
Code-Specific Risks
- Risk of under-documentation if phase is not specified.
Coding Notes
- Ensure documentation specifies the oral phase to avoid audits.
R13.12 - Dysphagia, oropharyngeal phase
Use when the patient has oropharyngeal phase dysphagia symptoms.
Applicable To
- Delayed swallow reflex
- Residue in valleculae
Excludes
- Oral phase dysphagia (R13.11)
Clinical Validation Requirements
- Delayed pharyngeal swallow
- Penetration to level of vocal folds
Coding Notes
Document specific findings like PAS scores to support code selection.
R13.14 - Dysphagia, pharyngoesophageal phase
Use when the patient has pharyngoesophageal phase dysphagia symptoms.
Applicable To
- Upper esophageal sphincter dysfunction
Excludes
- Oral phase dysphagia (R13.11)
- Oropharyngeal dysphagia (R13.12)
Clinical Validation Requirements
- UES dysfunction
- Bolus retention in pyriform sinuses
Coding Notes
Ensure documentation of therapeutic interventions.
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 Trouble Swallowing to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R13.11.
Impact
Clinical: May lead to inappropriate treatment plans., Regulatory: Increases risk of audit., Financial: Potential for reimbursement denials.
Mitigation Strategy
Include PAS scores and clinical signs in documentation.
Impact
Reimbursement: May lead to denials due to lack of specificity., Compliance: Triggers audits for unspecified coding., Data Quality: Reduces accuracy of clinical data.
Mitigation Strategy
Require FEES/VFSS results to assign R13.11-R13.14
Impact
Using R13.10 without specifying the phase can trigger audits.
Mitigation Strategy
Ensure documentation includes phase-specific details.
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 Trouble Swallowing, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Trouble Swallowing
Use these documentation templates to ensure complete and accurate documentation for Trouble Swallowing. These templates include all required elements for proper coding and billing.
Post-stroke dysphagia assessment
Specialty: Speech-Language PathologyRequired Elements
- Oral mechanism exam
- Swallow trials
- Instrumental assessment results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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