Home Health ICD-9/ICD-10 Alert

Question:

-- Louisiana Subscriber

The general rule when confronted with a symptom is: don't code the symptom when you have a definitive diagnosis. But even when you keep this general guideline in mind, symptoms can still trip you up.

A symptom code is one that describes some sign or symptom that the patient is experiencing without having a diagnosis that confirms the symptom.

So, if you have a patient who is exhibiting symptoms and you don't have a more definitive diagnosis it's appropriate to code for the symptom.

However, when certain symptoms indicate important problems that impact the care you provide, you should code for them. Listing a symptom code in these circumstances adds valuable information in addition to the known cause.

In your scenario, the patient's dysphagia is an important part of the care plan and requires specific interventions, so it's appropriate to code for the dysphagia. You'll list a code from the 787.2x (Dysphagia) series to report your patient's condition.

If you know which phase your patient's dysphagia is in, choose the appropriate fifth digit to provide the specifics, such as 787.21 (Dysphagia, oral phase). Without this detail, turn to 787.20 (Dysphagia, unspecified). The phase of dysphagia is usually determined by the speech language pathologist via the barium swallow.

Sequencing tip: When coding for dysphagia as a late effect of a cerebrovascular accident, you must list an additional code to describe the dysphagia type along with the combination code 438.82 (Other late effects of cerebrovascular disease; dysphagia). List 438.82 first, followed by the appropriate 787.2x code. Note: It is ok to sequence 787.20 after 438.82