2025 ICD-10-CM code R13.11
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms - Symptoms and signs involving the digestive system and abdomen Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Dysphagia, oral phase: Difficulty moving food or liquids from the mouth to the pharynx.
Medical necessity for this code would be established by documentation of significant difficulty with the oral phase of swallowing, such as impaired oral motor function, leading to risks of aspiration pneumonia, malnutrition, or dehydration.The physician must document the impact of the dysphagia on the patient's health and the need for intervention.
Diagnosis and management of dysphagia, including assessment of the oral phase of swallowing,referral to other specialists (e.g., speech therapist, gastroenterologist) as needed, and recommending appropriate interventions (e.g., dietary modifications, swallowing exercises).
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R13.1 (Dysphagia)
In simple words: This code means trouble swallowing food or drink from your mouth to your throat. It might hurt to swallow, or it might be hard to get the food started on its way down.
R13.11, Dysphagia, oral phase, denotes difficulty in the initial stage of swallowing, specifically the movement of food or liquids from the mouth to the pharynx (throat).This can manifest as various symptoms including but not limited to pain during swallowing (odynophagia), inability to initiate swallowing, food sticking in the mouth, or regurgitation.The condition is often associated with neurological disorders, anatomical abnormalities, or muscular dysfunction impacting the oral cavity.
Example 1: A 78-year-old patient with a history of stroke presents with difficulty initiating swallowing and pocketing food in the mouth. The oral phase is impaired., A 65-year-old patient with Parkinson's disease experiences reduced tongue movement and decreased oral sensation, leading to inefficient bolus formation and difficulty initiating swallowing., A 50-year-old patient post-surgical resection of an oral tumor has impaired motor control of the tongue and lips, resulting in difficulty chewing and initiating the swallowing process.
Detailed documentation specifying the patient's symptoms during the oral phase of swallowing, assessment of oral motor function (tongue mobility, lip closure, chewing ability), and any observations related to the patient's ability to initiate swallowing.Referral notes to a speech-language pathologist if consultation was obtained are essential.Imaging studies (e.g., videofluoroscopic swallowing study) reports, if performed, should be included.
** This code is used for diagnostic purposes.It is important to note that this is not a procedure code. Treatment would be coded separately (e.g., speech therapy).
- Payment Status: Active
- Specialties:Otolaryngology, Neurology, Gastroenterology, Speech-Language Pathology, Geriatrics
- Place of Service:Office, Hospital (Inpatient and Outpatient), Skilled Nursing Facility, Rehabilitation Facility