Gastroenterology Coding Alert

Knowing the phase of the condition will point you in the right direction.

You have to tread carefully while negotiating the various codes out there for dysphagia. One small mistake may lead to your whole claim falling apart. Lead yourself to success by keeping in mind these 3 tips.

Note: Dysphagia is the medical term for the symptom of difficulty in swallowing. Although classified under “symptoms and signs” in ICD-10, the term is sometimes used as a condition in its own right. Sufferers are sometimes unaware of this condition. However, persistent difficulty in swallowing may indicate a serious medical condition requiring treatment. For diagnostic gastroenterology, dysphagia is considered an important symptom for diseases of the esophagus and is considered a warning symptom for possible esophageal or gastroesophageal junction cancers.

Crossmatch Your Diagnosis to the Correct Type

Physicians usually refer patients with upper throat swallowing complaints to a speech-language pathologist (SLP) for an appropriate swallowing evaluation. This is particularly true when dysphagia is associated with cough or regurgitation of solid food. SLPs are the ones who usually diagnose dysphagia, determine what type (oral, pharyngeal or oropharyngeal) and develop a treatment plan.

The most common signs and symptoms commonly associated with dysphagia include pain while swallowing (odynophagia) or inability to swallow; sensation of food stuck in throat; drooling; hoarseness; regurgitation; frequent heartburn; acid reflux; unaccounted weight loss; and coughing, choking or gagging while swallowing.

After the gastroenterologist has identified the dysphagia phase he is treating or evaluating in his medical record you have the option of using any of the four ICD-9 codes that specify a type:

• Oral dysphagia: Disorders affecting the oral preparatory and oral propulsive phases usually result from impaired control of the tongue, although dental problems may also be involved. When eating solid food, patients may have difficulty chewing and initiating swallows.You will code it as 787.21 (Dysphagia, oral phase);
• Oropharyngeal dysphagia: It relates to difficulties experienced when the food bolus leaves the mouth and enters the pharynx. The correct code is 787.22 (Dysphagia, oropharyngeal phase);
• Pharyngeal dysphagia: This condition results from a weakness or lack of coordination of the pharyngeal muscles; aspiration is most likely to occur in this phase. You should report it with 787.23 (Dysphagia, pharyngeal phase).
• Pharyngoesophageal dysphagia: There is retention of food and liquid in the esophagus after swallowing due to impaired esophageal function. The correct code is 787.24 (Dysphagia, pharyngoesophageal phase). 

If the GI is unable to pinpoint the specific type of dysphagia, the condition could be defined as “not otherwise specified” (NOS), meaning that the information in the medical record is insufficient to assign a more specific diagnosis other than “dysphagia.” You should report the unspecified ICD-9 code 787.20 (Dysphagia, unspecified).

Tackle Coding of These Common Treatments 

Thankfully, while coding for treatments associated with GI dysphagia, the CPT® code 92526 (Treatment of swallowing dysfunction and/or oral function for feeding) is the single go-to code that almost always fits most aspects of treatments associated with dysphagia. This standalone code is all you need when the focus of the treatment is for swallowing especially when the service is provided by a non-physician provider including Speech Therapists, Occupational Therapists, or Physician Assistants. It is an untimed code, billed as 1 unit per day. The National Government Services LCD states: “CPT® code 92526 is a comprehensive code that includes most aspects of dysphagia treatment. Do not use additional CPT® codes in combination with 92526 when the focus of the treatment is for swallowing. CPT® code 97150 should be reported for group dysphagia treatment. Contractors pay for outpatient physical therapy services (which includes outpatient speech-language pathology services) and outpatient occupational therapy services provided simultaneously to two or more individuals by a practitioner as group therapy services (97150). The individuals can be, but need not be performing the same activity. The physician or therapist involved in group therapy services must be in constant attendance, but one-on-one patient contact is not required. (See CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230). If two or more shorter sessions are performed during the same day, these should be combined and billed as 1 unit.”

Treatment for esophageal dysphagia may include esophageal dilation, surgery to remove esophageal tumor or diverticulum, or medication. Severe dysphagia may require the insertion of a feeding tube (96.6, Enteral infusion of concentrated nutritional substances) or a percutaneous endoscopic gastrostomy tube (43.11, Percutaneous [endoscopic] gastrostomy [PEG]).

Payoff: The current Medicare rate for dysphagia treatment, 92526, is about $88 (based on RVU of 2.45 and a conversion factor of $35.8228). The treatment plan for dysphagia can include further diagnostic testing, diet/liquid modifications, oral motor exercises, deep pharyngeal neuromuscular stimulation (DPNS), or neuromuscular electrical stimulation (NMES).

Awareness of Cause Makes Coding Easier

Although your gastroenterologist makes the final call on the type of dysphagia, keeping yourselves aware of the common causes that may result in this condition will keep you ahead of the game. Some common causes of esophageal dysphagia may be:

• achalasia (530.0, Achalasia and cardiospasm); 
• esophageal spasm (530.5, Dyskinesia of esophagus);
• esophageal stricture (530.3, Stricture and stenosis of esophagus);
• esophageal tumors;
• gastroesophageal reflux disease (530.81, Esophageal reflux);
• eosinophilic esophagitis (530.13, Eosinophilic esophagitis); and
• systemic sclerosis (710.1, Systemic sclerosis).

Treatment for dysphagia mainly depends on the type or the underlying cause. Treatment for esophageal dysphagia may include esophageal dilation, surgery to remove esophageal tumor or diverticulum, or medication. Just remember that you should not sequence a symptom code as the principal diagnosis when a related definitive diagnosis has been established. 

Important: Because dysphagia is a symptom, it cannot be not be sequenced as the principal diagnosis if the underlying cause has been documented by the physician.