Otolaryngology Coding Alert

Question: An ENT diagnoses a patient with dysphonia and also finds that the patient has vocal nodules. Should I code both the symptom and the cause?

Minnesota Subscriber

Answer: "Yes, it is appropriate to code the symptom being treated and any disorders causing the symptom," instructs Nancy Swigert, MA, CCC-SLP, BRS-S, with ENT Associates in Clearwater, Fla. Here's how:

• List the condition being treated as the primary code.

• Report any medical cause as secondary.

For the speech-language pathologist, this would mean coding the dysphonia or the resonance disorder first and any medical cause as secondary. Check out these examples:

• dysphonia (784.42) secondary to complete unilateral paralysis of the vocal folds (478.32)

• hypernasality (784.43) secondary to history of unilateral cleft palate (749.01).