Pulmonology Coding Alert

Question: If the provider documents different phases of dysphagia, do you code the phases separately? For example, if the provider documents both oral dysphagia and pharyngeal dysphagia, would I use two separate codes?

Also, how would I code for odynophagia (pain with swallowing)?

Georgia Subscriber

Answer: You should clarify the documentation with the physician. The codes identify the distinct phases of dysphagia, so you’ll need to report the dysphagia based on the specific area listed in the documentation. For the two types mentioned in your question, you would use R13.11 (Dysphagia, oral phase) for oral dysphagia and R13.13 (Dysphagia, pharyngeal phase) for pharyngeal dysphagia. However, if the patient has both present, you may want to consider R13.12 (Dysphagia, oropharyngeal phase)

Finding the appropriate code for odynophagia is a little tricky. Pain in throat or pharynx codes may point you toward pharyngitis, which is not an accurate descriptor for this condition. In this scenario, it’s best to use R13.10 (Dysphagia, unspecified) to document odynophagia.