Home Health ICD-9/ICD-10 Alert

Precise dysphagia coding supports accurate reimbursement.

With the feds' increased focus on denying therapy visits, agencies can save themselves a lot of grief by selecting the correct dysphagia code.

"Identifying the specific code for this intricate disorder is the key for treatment," says Jun Mapili, PT, MAEd, coding supervisor with Global Home Care in Troy, MI.

When you admit a patient with dysphagia, the speech pathologist should evaluate the swallowing as soon as possible. This allows the precise coding needed to support the therapy visits--and justify payment for those visits from the Centers for Medicare & Medicaid Services.

Why worry? Treatment techniques the therapist will use are specific to the affected phase of swallowing, Mapili explains. Accurate coding helps ensure the treatment plan is on target. It will also help explain why the therapist is visiting the patient and what skills are needed during the visit.

Mapili's Dysphagia Tool Provides Details

The dysphagia tool included here will provide clinical details to help the coder code dysphagia specifically and correctly, Mapili says. Share it with clinicians to encourage them to communicate the information you need to do your job.
 
1. ICD code: 787.20 Dysphagia, unspecified

• Impaired structure/physiology: Unspecified
• Normal function: Undetermined due to un-specific clinical description
• Coding clue: Dysphagia is known but information at hand does not permit a more specific or "other" code assignment. Using this code may lead to a less specific treatment regimen.
 
2. ICD code: 787.21 Dysphagia, oral phase (oral preparation phase)

• Impaired structure/physiology: palate, tongue, lips, cheeks and mandible
• Normal function: The oral preparatory phase starts when food or liquid (the bolus) is chewed in preparation for swallowing; this phase is under voluntary neuromuscular control.
• Coding clue: The oral phase may be affected by surgical defects resulting in muscle weakness of the tongue or neurological disability.  These deficits can lead to outflow of oral contents before or after the swallow, resulting in leakage into the airway. It may also be the result of poor teeth, ill-fitting dentures, or a common cold. Other causes may include stroke or progressive neurological disorders, which may impair sensitivity, muscular coordination or render individuals unable to control or move the tongue.
 
3. ICD code: 787.22 Oropharyngeal phase (Oral propulsive phase)

• Impaired structure/physiology: tongue base and pharyngeal walls
• Normal function: This phase is also known as oral propulsive phase, in which the tongue pushes the food or liquid to the back of the mouth, beginning the swallowing response; this phase is under voluntary neuromuscular control.
• Coding clue: The most common symptom of oropharyngeal dysphagia is difficulty in swallowing liquids. Sufferers complain of food "sticking" in the throat. Many causes of oropharyngeal dysphagia are quite treatable. These include thyroid disease and myasthenia gravis, a disease in which nerve signals don't reach the muscle. Dysphagia caused by tumors or other structural lesions can be corrected with surgery. A number of therapy techniques are available that directly address these swallowing problems.

4. ICD code: 787.23 Pharyngeal phase

• Impaired structure/physiology: pharynx and larynx
• Normal function: pharyngeal phase begins when food or liquid quickly passes through the pharynx (the canal from the mouth to the esophagus) into the esophagus. In this phase the soft palate elevates, closing off the nasopharynx and preventing nasopharyngeal regurgitation; this phase is not under voluntary control. It's the shortest phase yet the most complex.
• Coding clue: A common cause of pharyngeal dysphagia is gastroesophageal reflux disease (GERD) when stomach acid moves up the esophagus to the pharynx, causing discomfort.

The most frequent problems that happen in the pharyngeal phase can be categorized into problems of timing (typically in neurological patients) and weakness of pharyngeal muscles. The swallow reflex does not trigger efficiently enough for the larynx to be guarded beneath the epiglottis. When this happens, food or liquid may penetrate and aspiration may occur.

Patients with pharyngeal deficits will have a high risk of "silent aspiration" due to diminished cough reflex and this may result in aspiration pneumonia or even death. However, do not rely on the presence of the coughing reflex alone when assessing swallowing function. Patients often require further diagnostic testing, such as a modified barium swallow or endoscopic evaluation of swallowing.

5. ICD code: 787.24 Pharyngoesophageal phase

• Impaired Structure/physiology: upper esophageal sphincter
• Normal function: Esophageal phase starts when the food or liquid moves through the esophagus into the stomach; this phase is not under voluntary control.
• Coding clue: The patient typically feels pain or discomfort lower down in the upper chest area, particularly shortly after swallowing. Some kinds of esophageal dysphagia can be treated with drugs such as cisapride or domperidone. Another approach is to use dilating devices, such as an inflatable balloon, to widen the esophagus.

When the cause is reflux esophagitis, the first treatment is anti-reflux therapy such as proton pump inhibitors and cisapride or domperidone, or, if these fail, dilation. Infections should be treated with the appropriate drugs. Tumors are usually treated with surgery.

6. ICD code: 787.29 Other dysphagia

• Impaired structure/physiology: Same as described above
• Normal function: The same as the phases described above
• Coding clue: Use this code when the information (dysphagia) is known but no separate code is provided.

Examples: Neurogenic dysphagia (causes may vary and include head trauma, motor neuron disease, Parkinson's disease, brain trauma, etc.); or cervical dysphagia (some causes of this include cerebral, peripheral neuropathic, muscular, crico-pharyngeal dysfunction, or local factors, such as inflammation from reflux).

Heads up: After Jan. 1, dysphagia coding will play an important part in home care reimbursement. When a diagnosis code for dysphagia appears on the OASIS assessment along with a response of "3: Enteral nutrition" on M0250 (Therapies the patient receives at home), the agency may receive extra case mix points. The same is true if the patient has a primary or other diagnosis of dysphagia along with a primary or other diagnosis of stroke.