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ICD-10 Coding for Vocal Cord Dysfunction(J38.5, J38.3)

Complete ICD-10-CM coding and documentation guide for Vocal Cord Dysfunction. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Paradoxical Vocal Fold MotionInducible Laryngeal Obstruction

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Related ICD-10 Code Ranges

Complete code families applicable to Vocal Cord Dysfunction

J38-J39Primary Range

Diseases of the larynx and vocal cords

This range includes conditions affecting the vocal cords, including functional and structural disorders.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
J38.5Laryngeal spasmUse when there is documented paradoxical movement of the vocal cords causing symptoms.
  • Laryngoscopy showing paradoxical vocal fold motion during inspiration
  • Negative bronchoprovocation challenge to rule out asthma
J38.3Other diseases of vocal cordsUse when structural lesions are present on the vocal cords.
  • Laryngoscopy confirming structural lesions

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 vocal cord dysfunction

Essential facts and insights about Vocal Cord Dysfunction

The ICD-10 code for vocal cord dysfunction is J38.5, which includes laryngeal spasm and paradoxical vocal fold motion.

Primary ICD-10-CM Codes for vocal cord dysfunction

J38.5
Laryngeal spasm
Billable Code

Decision Criteria

clinical Criteria

  • Presence of paradoxical vocal fold motion confirmed by laryngoscopy

documentation Criteria

  • Detailed description of symptoms and exclusion of asthma

Applicable To

  • Paradoxical vocal fold motion
  • Vocal cord dysfunction

Excludes

  • Structural lesions of the vocal cords

Clinical Validation Requirements

  • Laryngoscopy showing paradoxical vocal fold motion during inspiration
  • Negative bronchoprovocation challenge to rule out asthma

Code-Specific Risks

  • Misclassification if structural lesions are present

Coding Notes

  • Ensure documentation specifies functional disorder without structural lesions.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Other abnormal breathing

R06.89
Use to capture additional respiratory symptoms.

Other respiratory disorders

J98.09
Use for other unspecified respiratory conditions.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Other diseases of vocal cords

J38.3
Use J38.3 for structural lesions like granuloma or leukoplakia.

Laryngeal spasm

J38.5
Use J38.5 for functional disorders without structural lesions.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Vocal Cord Dysfunction to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code J38.5.

Impact

Clinical: May lead to misdiagnosis., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.

Mitigation Strategy

Use specific medical terminology., Include diagnostic test results.

Impact

Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.

Mitigation Strategy

Use J38.5 for functional disorders like VCD.

Impact

Incorrect code selection between J38.3 and J38.5.

Mitigation Strategy

Ensure thorough documentation of clinical 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 Vocal Cord Dysfunction, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Vocal Cord Dysfunction

Use these documentation templates to ensure complete and accurate documentation for Vocal Cord Dysfunction. These templates include all required elements for proper coding and billing.

ENT Progress Note for VCD

Specialty: Otolaryngology

Required Elements

  • Subjective symptoms
  • Objective laryngoscopy findings
  • Assessment and plan

Example Documentation

**Subjective:** "Pt reports sudden-onset inspiratory stridor when exposed to strong odors, no relief with albuterol." **Objective:** - Flexible laryngoscopy: Vocal folds adducted 80% during inspiration, normal expiration - Spirometry: FEV1 95% predicted, flattened inspiratory curve **Assessment:** J38.5 - Vocal cord dysfunction with confirmed paradoxical motion **Plan:** Speech therapy referral for breathing retraining

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has breathing difficulty.
Good Documentation Example
Patient presents with inspiratory stridor, voice changes, and laryngoscopy shows paradoxical vocal fold adduction during inspiration.
Explanation
The good example provides specific symptoms and diagnostic findings supporting the diagnosis.

Need help with ICD-10 coding for Vocal Cord Dysfunction? Ask your questions below.

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