Find information on swallowing difficulty, also known as dysphagia. This resource covers clinical documentation, medical coding (ICD-10 codes), diagnosis, and treatment of swallowing disorders for healthcare professionals. Learn about the causes, symptoms, and evaluation of dysphagia, including oropharyngeal dysphagia and esophageal dysphagia. Explore best practices for accurate medical coding and comprehensive clinical documentation related to swallowing problems. Improve your understanding of patient care related to difficulty swallowing.
Also known as
Dysphagia
Difficulty swallowing solids, liquids, or both.
Esophagitis
Inflammation of the esophagus, sometimes causing dysphagia.
Pain on swallowing
Odynophagia, often associated with difficulty swallowing.
Sequelae of stroke
Swallowing problems can be a lasting effect of a stroke.
Follow this step-by-step guide to choose the correct ICD-10 code.
Dysphagia related to solids/liquids?
Solids and liquids
Oropharyngeal phase?
Solids only
Progressive?
Liquids only
Consider neuromuscular or oropharyngeal causes. R13.1x, specify if paralysis/weakness (R13.12) or other (R13.19)
None of the above
Document the specific difficulty and consider other appropriate codes (e.g., globus sensation (R45.0), odynophagia (R68.1), psychogenic dysphagia (F45.3)). If dysphagia cannot be further clarified use R13.9.
When to use each related code
| Description |
|---|
| Swallowing difficulty |
| Odynophagia |
| Globus sensation |
Coding R13.1 (Swallowing Difficulty) without sufficient documentation specifying the type or cause can lead to claim denials and inaccurate quality reporting.
Miscoding oropharyngeal dysphagia (e.g., R13.10, R13.11) with esophageal dysphagia (e.g., R13.12) impacts reimbursement and clinical data accuracy.
Insufficient documentation of underlying conditions contributing to dysphagia (e.g., stroke, neurological disorders) can affect severity coding and case mix index.
Patient presents with complaints of dysphagia, or swallowing difficulty. Onset of symptoms is reported as [duration and onset details - e.g., gradual over the past three months, sudden onset two days ago]. Patient describes the nature of the swallowing difficulty as [specific description - e.g., difficulty initiating a swallow, feeling of food sticking in the throat or chest, coughing or choking while swallowing, nasal regurgitation]. Symptoms are [frequency - e.g., intermittent, constant] and occur with [consistency - e.g., solids, liquids, both]. Associated symptoms include [list associated symptoms - e.g., odynophagia, weight loss, heartburn, voice changes, aspiration pneumonia]. Patient's medical history includes [relevant medical history - e.g., stroke, GERD, Parkinson's disease, head and neck cancer, esophageal stricture]. Medications include [list current medications]. Physical examination reveals [relevant findings - e.g., decreased tongue strength, impaired gag reflex, cervical lymphadenopathy]. Differential diagnosis includes [list potential diagnoses - e.g., oropharyngeal dysphagia, esophageal dysphagia, achalasia, Zenker's diverticulum]. Plan includes [diagnostic testing - e.g., modified barium swallow study, esophagoscopy, esophageal manometry] and [treatment plan - e.g., referral to speech-language pathologist for swallowing therapy, dietary modifications, medication management]. ICD-10 code: [appropriate ICD-10 code - e.g., R13.10 for Dysphagia, unspecified]. Further evaluation and management will be based on diagnostic testing results.