Home Health ICD-9/ICD-10 Alert

Question: I'd like to make sure I'm coding for dysphagia correctly. For example, if a patient has a diagnosis of cancer of the esophagus, and the patient is on a gastrostomy tube, do I still need to code dysphagia? Why or why not? And are there any intricacies to using the new codes that I should keep in mind?

-- New Jersey Subscriber

Answer: The question whether a symptom is integral or not is a common one, says coding consultant Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates. The general rule is that if a symptom is integral to the condition, it is not necessary to also code the symptom. However, you should code certain symptoms which represent important problems in medical care and which might be desirable to classify in addition to the known cause.

In your scenario the patient's dysphagia was an important part of the care plan and required specific interventions, therefore the dysphagia should be coded, Selman-Holman says. Under the new PPS, if you don't code for dysphagia, you'll lose 6 points in the clinical domain.