Understanding Recurrent Throat Clearing diagnosis, documentation, and medical coding? Find information on causes, evaluation, and treatment of chronic throat clearing. Explore clinical documentation best practices, ICD-10 codes, and differential diagnosis considerations for throat clearing. Learn about related symptoms like cough, globus sensation, and throat irritation. This resource offers guidance for healthcare professionals on accurately documenting and coding recurrent throat clearing in medical records.
Also known as
Other speech disturbances
Includes throat clearing as a specified speech disturbance.
Chronic laryngitis and laryngotracheitis
Inflammation of the larynx can cause throat clearing.
Diseases of the respiratory system
Encompasses various respiratory conditions that may cause throat clearing.
Other somatoform disorders
May be considered if throat clearing is a psychogenic tic.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is throat clearing due to a known structural abnormality?
Yes
Specify abnormality (e.g., Laryngeal web)
No
Is throat clearing due to a known medical condition (e.g., GERD)?
When to use each related code
| Description |
|---|
| Recurrent Throat Clearing |
| Postnasal Drip |
| Laryngopharyngeal Reflux |
Coding R49.89 (Other specified symptoms and signs involving the throat and chest) without sufficient clinical documentation to support a more specific diagnosis like a tic disorder or GERD.
Failing to capture underlying conditions (e.g., allergies, post-nasal drip, anxiety) contributing to throat clearing, impacting accurate risk adjustment and reimbursement.
Insufficient physician documentation specifying the frequency, duration, and associated symptoms of throat clearing hindering accurate code assignment and audit defense.
Patient presents with a chief complaint of recurrent throat clearing. The patient reports experiencing frequent, involuntary throat clearing episodes, described as a persistent urge to clear the throat despite the absence of secretions or a foreign body sensation. Onset of symptoms is reported as [duration]. The patient denies associated symptoms such as dysphagia, odynophagia, dyspnea, or hoarseness. The patient also denies any recent upper respiratory infections, allergies, or exposure to irritants. Medical history is significant for [relevant medical history, e.g., anxiety, GERD, vocal cord dysfunction]. Social history includes [smoking status, alcohol use, occupational vocal demands]. Physical examination reveals normal oropharynx and larynx without erythema, edema, or lesions. No palpable cervical lymphadenopathy. Vocal quality is normal. Differential diagnosis includes habit cough, tic disorder, laryngopharyngeal reflux, and vocal cord dysfunction. Assessment: Recurrent throat clearing, likely secondary to [probable cause, e.g., habit, anxiety, LPR]. Plan includes patient education regarding throat clearing and its potential impact on vocal health. Behavioral modification techniques, including vocal hygiene strategies, are recommended. Consider referral to speech-language pathology for voice therapy and evaluation for potential underlying laryngeal hypersensitivity or muscle tension dysphonia. If LPR is suspected, trial of proton pump inhibitor therapy may be warranted. Follow-up scheduled in [duration] to assess response to treatment. ICD-10 code: [appropriate ICD-10 code, e.g., 784.19 - Other symptoms involving respiratory system and other chest symptoms]. CPT codes may include [appropriate CPT codes depending on services rendered, e.g., 92507 - Speech sound production materials provided].