Pulmonology Coding Alert

Question: My pulmonologist diagnosed a patient with nasopharyngeal carcinoma status post radiation and chemo with subsequent dysphagia and nasopharyngeal stenosis. Can I code the dysphagia as oropharyngeal phase when the note does not specifically mention the condition as such?

Answer: If the pulmonologist doesn't specify in her notes the type of dysphagia the patient has, you should opt for dysphagia unspecified or 787.20. ICD-9 787.22 (Dysphagia; oropharyngeal phase) represents "impaired structure/ physiology of tongue base and pharyngeal walls," according to the American Speech-Language-Hearing Association (ASHA). On the other hand, 787.21 (... oral phase) describes "impaired structure/physiology of palate, tongue, lips, cheeks", while 787.23 (... pharyngeal phase) represents "impaired structure/ physiology of pharynx and larynx."

ICD-9 787.22 has better specificity of the affected swallowing disorder phase. For instance, a patient with oral dysphagia has difficulty in the voluntary transfer of food from the mouth to the pharyx. In pharyngeal dysphagia, the patient has difficulty in reflexive transfer of food from pharynx to initiate involuntary esophageal phase of swallowing while protecting airway from misdirection of food. In this case, the patient usually undergoes further testing to identify the affected phase. If the test 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, the physician or speech language pathologist would diagnose oropharyngeal dysphagia (787.22).