Pick the Right Code for Pediatric Dysphagia Choosing the appropriate medical diagnosis can be key to reimbursement for swallowing treatment with children. Bottom Line
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Bottom Line  |   May 01, 2017
Pick the Right Code for Pediatric Dysphagia
Author Notes
  • Janet McCarty, MEd, CCC-SLP, is director of ASHA private health plan reimbursement. jmccarty@asha.org
    Janet McCarty, MEd, CCC-SLP, is director of ASHA private health plan reimbursement. jmccarty@asha.org×
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Swallowing, Dysphagia & Feeding Disorders / Bottom Line
Bottom Line   |   May 01, 2017
Pick the Right Code for Pediatric Dysphagia
The ASHA Leader, May 2017, Vol. 22, 28-29. doi:10.1044/leader.BML.22052017.28
The ASHA Leader, May 2017, Vol. 22, 28-29. doi:10.1044/leader.BML.22052017.28
If you treat children with dysphagia, do you know how to appropriately code their diagnoses? To a certain extent, choosing the correct code depends on whether the swallowing or feeding difficulty is neurologically based or behaviorally based.
ICD-10-CM (“International Classification of Diseases, 10th Revision, Clinical Modification”) lists several diagnostic codes to describe services. Clinicians need to review the patient’s history and etiology in deciding which code to select.
What are the available dysphagia codes?
For children with related medical conditions, such as neurological disorders or structural abnormalities, the dysphagia codes to consider are:
  • R13.11, Dysphagia, oral phase

  • R13.12, Dysphagia, oropharyngeal phase

  • R13.13, Dysphagia, pharyngeal phase

  • R13.14, Dysphagia, pharyngoesophageal phase

  • R13.19, Other dysphagia

  • R13.10, Unspecified dysphagia. This code is not recommended under most circumstances because, by definition, unspecified codes indicate that there is insufficient information in the medical record to assign a more specific code. Payers rarely allow unspecified codes.

Do I need to choose a secondary medical diagnosis?
Health plans often require a secondary medical diagnosis—such as cerebral palsy—to support the dysphagia code. However, in some scenarios—such as oral-motor swallowing dysfunction alone—an additional code is not relevant.
What about treatment for food-texture sensitivity?
Health plans may deny dysphagia treatment for children who have sensitivity to food textures. ASHA maintains that the inability to manage age-appropriate food textures is considered oral-stage dysphagia (ICD-10 code R13.11), a position supported by several ASHA documents. If documentation supports an oral-function impairment, R13.11 is an appropriate, stand-alone diagnosis.
What’s the code for a behavioral feeding difficulty?
Children who have no oral-motor weakness or associated symptoms—such as coughing—may demonstrate a significant feeding problem. Assigning R13.11 for this apparent behavior-based difficulty would be challenging for this scenario. SLPs might consider using code R63.3, described as “feeding difficulties.” Although additional descriptive text for this code notes “Feeding problem (elderly) (infant) NOS [not otherwise specified],” the code is not limited to only older adults or infants.
According to the official ICD-10-CM guidelines, any descriptions in parentheses are referred to as “nonessential modifiers,” which are terms that may coexist with the main term but do not change the code assignment for the condition. Under this guideline, R63.3 may be used for a child who has a significant feeding disorder but no documented oral dysfunction. R63.3 does, however, exclude feeding problems of newborns (the P92 series) and infant feeding disorders of nonorganic origin (the F98.2 series)—such as anorexia—that SLPs do not treat.

Accurate diagnostic code assignment does not guarantee payment. Coverage is based on criteria established by the patient’s payer.

What other codes are available?
An additional ICD-10 code to consider is Z72.4, inappropriate diet and eating habits, found under the heading “Problems related to lifestyle.” It excludes behavioral eating disorders of infancy or childhood (F98.2–F98.3). Z codes describe “factors influencing health status and contact with health services.” Not all payers recognize these codes, which are typically used for patients seeking treatment for reasons other than a disease or injury.
If the code is correct, will services be reimbursed?
Accurate diagnostic code assignment does not guarantee payment. Coverage is based on criteria established by the patient’s payer.
ASHA’s Practice Portal includes a detailed overview of and clinical parameters for pediatric dysphagia. In addition, the North Carolina Medicaid program’s policy on swallowing and feeding deficits may serve as an example of—and be similar to other payers’—coverage considerations and diagnostic code assignment.
The North Carolina policy notes that to bill procedure code 92526 (swallowing and feeding treatment), at least one of the bulleted deficits must be documented:
  • Coughing and/or choking while eating or drinking.

  • Coughing, choking or drooling with swallowing.

  • Wet-sounding voice.

  • Changes in breathing when eating or drinking.

  • Frequent respiratory infections.

  • Known or suspected aspiration pneumonia.

  • Masses on the tongue, pharynx or larynx.

  • Muscle weakness, or myopathy, involving the pharynx.

  • Neurologic disorders likely to affect swallowing.

  • Medical issues that affect feeding, swallowing and nutrition.

  • Oral function impairment or deficit that interferes with feeding.

These findings must be indicated through videofluoroscopy, fiberoptic endoscopic evaluation of swallowing, or a clinical feeding and swallowing evaluation.
The policy also stipulates that a 92526 claim should not be submitted for treatment to decrease food aversions, increase food repertoire, and expand tolerance to different textures of foods related to nutritional feeding disorders and feeding development unless at least one of the specified deficits is documented.
A post on the ASHA Leader Blog, “More Than a Picky Eater: How to Really Know?” by April Anderson may also help SLPs determine if a child has a clinical swallowing or feeding problem.
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May 2017
Volume 22, Issue 5