Cardiology Coding Alert

Question: According to my cardiologist’s documentation, the patient has dysphagia in its pharyngeal phase four months following a cerebral infarction. Which ICD-10-CM code should I report for this diagnosis?

Ohio Subscriber

Answer: In this case, you should actually report two ICD-10-CM codes on your claim.

First, you should report I69.391 (Dysphagia following cerebral infarction).

Additionally, a note under code I69.391 tells you to report an additional code to identify the type of dysphagia, if it is known. From the medical documentation, you know that the dysphagia is pharyngeal, so you should report R13.13 (Dysphagia, pharyngeal phase).