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2025 ICD-10-CM code I69.891

Dysphagia following other cerebrovascular disease. Use additional code to identify the type of dysphagia, if known (R13.11-R13.19).

Do not use I69.891 for dysphagia directly resulting from traumatic intracranial injury (S06.-).Use a code from category I69 only for sequelae (late effects) of cerebrovascular disease. If the dysphagia is a direct result of the current cerebrovascular event, code the underlying condition first.

Medical necessity for services related to dysphagia following a cerebrovascular event must be established by documenting the functional impairment and its impact on the patient's nutrition, hydration, and overall health.The need for diagnostic testing, therapeutic interventions (e.g., speech therapy, dietary modifications), and any associated treatments should be clearly justified.

Clinicians should document the specific type of dysphagia (e.g., oral, oropharyngeal) and its impact on the patient's ability to swallow different consistencies.Assessment of swallowing function and nutritional status is crucial.

IMPORTANT:Use additional code to identify the type of dysphagia, if known (R13.11-R13.19). Use additional code to identify presence of: alcohol abuse and dependence (F10.-), exposure to environmental tobacco smoke (Z77.22), history of tobacco dependence (Z87.891), hypertension (I10-I1A), occupational exposure to environmental tobacco smoke (Z57.31), tobacco dependence (F17.-), tobacco use (Z72.0)

In simple words: Difficulty swallowing after a stroke or other cerebrovascular problem (excluding head injuries).

Dysphagia following other cerebrovascular disease. This code is used to indicate difficulty swallowing as a consequence of a cerebrovascular event, excluding traumatic intracranial injury and other specified conditions.Use additional code to identify the type of dysphagia, if known (R13.11-R13.19).

Example 1: A patient experiences difficulty swallowing solids and liquids following a stroke. After a swallowing evaluation, the dysphagia is diagnosed and I69.891 is used, along with a code specifying the type of dysphagia (e.g., R13.12 for oropharyngeal dysphagia)., A patient with a history of cerebrovascular disease develops dysphagia and aspiration pneumonia.I69.891 is used to code the dysphagia as a sequela of the cerebrovascular disease, and an additional code is used for the pneumonia., A patient presents with dysphagia following a cerebral infarction. The dysphagia is determined to be a direct result of the infarction. I69.391 (Dysphagia following cerebral infarction) would be used instead of I69.891, as the infarction code is more specific.

Documentation should include details of the cerebrovascular event, the nature and severity of the dysphagia (including the phase affected and consistencies involved), results of swallowing assessments (e.g., modified barium swallow study), and any associated complications (e.g., aspiration pneumonia).

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