Patient presents with complaints of dysphagia, difficulty swallowing, or swallowing problems.  Onset of symptoms is described as (acute, subacute, chronic) and began (duration and timeframe).  Patient reports (intermittent or constant) difficulty swallowing (solids, liquids, or both).  Associated symptoms may include odynophagia (painful swallowing), globus sensation (lump in throat), choking, coughing, regurgitation, heartburn, weight loss, or aspiration pneumonia symptoms such as fever, cough, and shortness of breath.  The patient denies (or reports) any history of stroke, neurological disorders, head and neck cancer, esophageal stricture, GERD, eosinophilic esophagitis, or prior esophageal surgery.  Physical examination reveals (normal or abnormal findings related to oral cavity, pharynx, larynx, and neck).  Assessment suggests possible diagnoses including oropharyngeal dysphagia, esophageal dysphagia, functional dysphagia, or other swallowing disorders.  Differential diagnosis includes achalasia, esophageal spasm, esophageal diverticulum, Zenker's diverticulum, and other motility disorders.  Plan includes a referral to (speech-language pathologist, gastroenterologist, otolaryngologist) for further evaluation including a videofluoroscopic swallow study (VFSS or modified barium swallow study), esophagogastroduodenoscopy (EGD), esophageal manometry, or other diagnostic testing as indicated.  Patient education provided on swallowing techniques, dietary modifications (including thickened liquids or pureed diet), and aspiration precautions.  Follow-up scheduled to review test results and discuss treatment options including swallowing therapy, medication management, or other interventions as appropriate.  Medical billing and coding will utilize ICD-10 codes for dysphagia (R13.10, R13.11, R13.12, R13.19) and other relevant diagnoses, along with CPT codes for evaluation and management services, diagnostic procedures, and therapeutic interventions.