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Coding A More Specific Dx

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CCO_Admin

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Keith Phillips asked:

Hi everyone. If the attending physician has a diagnosis of dysphagia but the respiratory therapist that came in and did a dysphagia assessment determined that it was oropharyngeal phase dysphagia (R13.12).

Would it be acceptable for me to use that more specific diagnosis? I feel like I could use that more specific diagnosis because the physician and therapist both agree that the patient has dysphagia but a part of me feels like I should not. Thanks for any input!

Answer:

Both providers concur that the patient has dysphagia (R13.10) which is unspecified. However; the respiratory therapist gave a more definitive diagnosis; still dysphagia - but oropharyngeal phase dysphagia (R13.12).
Code the more definitive diagnosis. It was her findings.
 
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