Otolaryngology Coding Alert

Question: A patient with nasopharyngeal carcinoma S/P radiation and chemo has subsequent dysphagia and nasopharyngeal stenosis. Can I code the dysphagia as oropharyngeal phase when the note does not specifically mention the condition as oropharyngeal phase?

Maryland Subscriber

Answer: If the otolaryngologist's note does not fully describe the dysphagia, you should opt for dysphagia unspecified or 787.20. Code 787.22 (Dysphagia; oropharyngeal phase) represents "impaired structure/physiology of tongue base and pharyngeal walls," according to the American Speech-Language-Hearing Association (ASHA). In comparison, 787.21 (- oral phase) describes "impaired structure/physiology of palate, tongue, lips, cheeks" and 787.23 (- pharyngeal phase) represents "impaired structure/physiology of pharynx and larynx."

ASHA requested the expansion of 787.2 in 2007 to better specify the affected swallowing disorder phase. "Dysphagia symptoms significantly vary depending on the affected phase," and "Treatment strategies are specific to the affected phase of swallowing," ASHA commented in the 2006 presentation "Hearing and Swallowing Disorders ICD-9-CM Recommendations." For instance, a patient with oral dysphagia has difficulty in the voluntary transfer of food from the mouth to the pharynx. In pharyngeal dysphagia, reflexive transfer of food from pharynx to initiate involuntary esophageal phase of swallowing while protecting airway from misdirection of food is difficult.

The patient may require further testing to identify the affected phase. For instance, videofluoroscopic evaluation (92611, Motion fluoroscopic evaluation of swallowing function by cine or video recording) reveals difficulty with preparation of the bolus, premature loss over back of tongue, some penetration into upper laryngeal vestibule and residue in pyriforms with risk of aspiration. In this case, the physician or speech language pathologist would diagnose oropharyngeal dysphagia, and you would select 787.22.