2025 ICD-10-CM code R13.10
Dysphagia, unspecified. Difficulty in swallowing.
Medical necessity for services related to dysphagia is established by the presence of signs, symptoms, and/or abnormal findings that indicate a potential underlying medical condition requiring evaluation and/or treatment.
Clinicians responsible for diagnosing and managing dysphagia include primary care physicians, gastroenterologists, otolaryngologists, and neurologists, depending on the underlying cause.It is important to investigate the cause of dysphagia to determine the appropriate treatment.
- 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- Symptoms and signs involving the digestive system and abdomen (R10-R19)
In simple words: This code indicates difficulty swallowing with no specific cause identified.
Dysphagia is the medical term for difficulty swallowing.This code specifies that the dysphagia is unspecified, meaning there is no further detail about the nature or cause of the swallowing difficulty.
Example 1: A 65-year-old patient presents with a new complaint of difficulty swallowing both solids and liquids.Initial evaluation does not reveal a specific cause, and further investigation is required., A patient with a history of stroke reports ongoing difficulty swallowing.This is documented as dysphagia following cerebrovascular disease (I69.-91)., A 30-year-old patient experiences brief episodes of difficulty swallowing during a period of high stress. The symptoms resolve, and no cause is determined after investigation.
Documentation should include the type of dysphagia (difficulty with solids, liquids, or both), onset, frequency, associated symptoms (e.g., pain, regurgitation, weight loss), and any relevant medical history.Results of diagnostic tests (e.g., barium swallow, endoscopy) should also be documented.
** Psychogenic dysphagia should be coded using F45.8.
- Specialties:Gastroenterology, Otolaryngology, Internal Medicine, Neurology, Family Medicine
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Skilled Nursing Facility, Nursing Facility