Otolaryngology Coding Alert

Get ready to rely more on specific voice and speech disturbance codes and less on catch-all codes. Thanks to ICD-9 2010 creations, you can specify several symptoms involving the head and neck in the 784.4 and 784.5 subcategories.

Otolaryngologists and speech-language pathologists use different methods to evaluate and treat dysphonia and hyper/hyponasality. "Now they have new codes to use when they do that," says Nancy Swigert, MA, CCC-SLP, BRS-S, with ENT Associates in Clearwater, Fla.

Take these steps to make sure your superbill's throat codes won't leave you choking on rejections come this fall and winter (Some insurers may not require the new codes on their ICD-9 2010 HIPAA-compliant date of Oct. 1).

Once insurers start to accept ICD-9 2010 diagnoses, pause before you automatically use 784.40. Your 2009 superbill should describe this code as "Voice disturbance, unspecified."

Change: ICD-9 2010 revises this code to "Voice and resonance disorder, unspecified." "It is never a good idea to use an 'unspecified' code when much more specific codes exist," says Swigert, who is a speech-language pathologist (SLP) and a board-recognized specialist in swallowing and swallowing disorders.

You'll instead have three additional codes that may better describe the patient's voice and resonance disorder. ICD-9 2010 introduces:

• 784.42 -- Dysphonia

• 784.43 -- Hypernasality

• 784.44 -- Hyponasality.

ICD-9 2009 lumps these terms under 784.49 (Voice disturbance; other). "The main reason the American Speech-Language-Hearing Association requested these additions is that it wasn't appropriate to group these conditions together," says Dee Adams Nikjeh, PhD, CCC-SLP, ASHA Health Care Economics Committee vice chair and ASHA Relative Value Update Committee (RUC) Health Care Professions Advisory Committee (HCPAC) alternate. Dysphonia relates to voice and hypernasality/hyponasality relate to resonance.

You can keep the new codes straight if you link their conditions to their anatomical counterparts. Relate 784.42 to the following structure:

Larynx: Dysphonia (784.42) is a problem with phonation or voice production, which indicates a problem in the larynx. "Patients with dysphonia are typically seen first by an otolaryngologist to assess the larynx to determine if there are any pathologies," says Swigert, who is director of speech-language pathology and respiratory care at Central Baptist Hospital in Lexington, Ky.

After initial evaluation, the otolaryngologist would then also use more specific diagnoses for any pathologies found, such as vocal nodules. An SLP would assess the patient's symptoms to further describe the dysphonia. You would code the symptom being treated (784.42) and any disorders causing the symptom (for instance, 478.32, Paralysis of vocal cords or larynx; unilateral, complete) (For more on coding these combinations, see "Reader Question: Code Dysphonia + Tumor ICD-9 Codes" on page 78).

Relate 784.43 and 784.44 to the oral palate. Hypernasality and hyponasality are problems of resonance or sound quality. "Resonance indicates there's something wrong with the soft palate or velopharyngeal port," says Nikjeh, who is also an assistant research professor at Tampa's University of South Florida Department of Communication Sciences and Disorders.

The SLP would assess the individual's production of speech sounds and determine if there is adequate balance  of airflow to the nasal and oral cavities (meaningresonance), Swigert explains. If the airflow into the nasopharynx is excessive, causing a perception of hypernasality, the appropriate code is 784.43. If the airflow into the nasopharynx is blocked, causing a perception of hyponasality, you would use 784.44.

Step 5: Break Out Dysarthria Using 784.51 or 483.41

Dysarthria (slurred speech) will get its own code in two places, Nikjeh points out. Using ICD-9 2009, you have to group the symptom under "other speech disturbance" (784.5 in ICD-9 2009).

New way: In ICD-9 2010, you not only specifically identify dysarthria, you also differentiate whether the  dysarthria speech is due to stroke. Here's how:

• For dysarthria (slurred speech), the appropriate ICD-9 2010 code is 784.51.

• If the slurred speech was due to late effects of a stroke or cerebrovascular (CVA) disease, you would instead use 438.13, as noted in an exceptions note following 784.51.

If you don't add a fifth digit onto your superbill entry for 784.5 (Other speech disturbance), prepare for denials  when this code becomes invalid on Oct. 1, per ICD-9 2010.The code will require a fifth digit of "9" to indicate other (784.59) or as discussed above a "1" for dysarthria (784.51).

Helpful: Check out two additional symptoms that will fall under 784.59. "Dysphagia" as a speech disturbance goes to the "other voice and resonance disorders" code. Defect/disturbance, secondary to organic lesion, also maps to 784.59, according to the ICD-9-CM 2010 Alphabetic Index. Make sure to use the more specific swallowing codes when your ENT or SLP evaluates or treats the clinical phase of dysphagia (787.20-787.29).