2025 ICD-10-CM code I69.391
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Cerebrovascular diseases - Sequelae of cerebral infarction Diseases of the circulatory system (I00-I99) Feed
Dysphagia following cerebral infarction.Use additional code to specify dysphagia type if known.
Modifiers may be applicable depending on the circumstances of the service provided. Consult the official coding guidelines for appropriate modifier use.
Medical necessity for coding I69.391 is established by the presence of documented dysphagia directly resulting from a previous cerebral infarction.The severity of the dysphagia, the impact on the patient's nutritional status, and the need for interventions (e.g., swallowing therapy, modified diet) support medical necessity.
The clinical responsibility for coding I69.391 rests primarily with the physician or other qualified healthcare provider diagnosing and managing the patient's condition after a cerebral infarction.Speech-language pathologists play a key role in assessing and treating the dysphagia, often providing documentation that informs the coding process.Accurate coding requires collaboration between the medical and therapy teams.
In simple words: This code means difficulty swallowing that happened after a stroke.The doctor might use another code to explain exactly what type of swallowing problem the patient has.
This ICD-10-CM code, I69.391, designates dysphagia (difficulty swallowing) as a sequela (a condition that develops as a result of a previous disease or injury) of a cerebral infarction (stroke).It's crucial to note that this code should be used in conjunction with an additional code specifying the type of dysphagia present (e.g., oral phase, pharyngeal phase), if the information is available, using codes from the R13.1- range. This ensures complete and accurate documentation of the patient's condition.The code excludes cases of dysphagia resulting from other causes, such as trauma or non-vascular diseases.
Example 1: A 72-year-old patient presents with dysphagia following a left-hemisphere ischemic stroke.The SLP assessment reveals oropharyngeal dysphagia, requiring modified diet and swallowing therapy.The physician documents the stroke and the SLP documents the dysphagia type. Codes I63.9 (ischemic stroke) and I69.391, along with R13.12 (oropharyngeal dysphagia), are used., A 65-year-old patient experiences dysphagia after a hemorrhagic stroke.Neurological exam reveals right-sided weakness and difficulty initiating swallowing (oral phase dysphagia).The physician codes I61.9 (intracerebral hemorrhage) and I69.391, along with R13.11 (oral phase dysphagia) to reflect the patient's condition., A patient with a history of cerebral infarction is admitted to a rehabilitation facility. The patient presents with persistent dysphagia affecting both oral and pharyngeal phases. The medical team documents the history of infarction and the clinical findings of dysphagia. The physician codes I69.391, while the SLP conducts a thorough evaluation and codes both R13.11 and R13.12 to capture the complexities of the dysphagia.
Physician documentation of the cerebral infarction (including type, location, and date), SLP assessment and report detailing the type and severity of dysphagia (including specific phase(s) involved), and any supporting diagnostic tests (e.g., videofluoroscopic swallowing study) are crucial for accurate coding.The documentation must clearly link the dysphagia to the cerebral infarction.
** This code should be used only when the dysphagia is directly attributed to a cerebral infarction.Cases of dysphagia resulting from other neurological conditions or causes require different coding.
- Payment Status: Active
- Modifier TC rule: Not applicable to this ICD-10 code.
- Specialties:Neurology, Speech-Language Pathology, Rehabilitation Medicine
- Place of Service:Inpatient Hospital, Outpatient Hospital, Rehabilitation Facility, Skilled Nursing Facility, Physician's Office, Home Health