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ICD-10 Guide
ICD-10 CodesJ38.01

J38.01

Paralysis of vocal cords and larynx, unilateral

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/06/2025

Code Description

ICD-10 J38.01 is a billable code used to indicate a diagnosis of paralysis of vocal cords and larynx, unilateral.

Key Diagnostic Point:

J38.01 refers to unilateral paralysis of the vocal cords and larynx, which can significantly impact a patient's ability to speak and breathe. The vocal cords, located in the larynx, are essential for phonation and airway protection. Unilateral paralysis may result from various causes, including neurological disorders, trauma, or surgical complications. Clinically, patients may present with hoarseness, breathiness, or a weak voice, and in severe cases, may experience stridor or difficulty breathing. The progression of the condition can vary; some patients may recover spontaneously, while others may require interventions such as voice therapy or surgical procedures to improve vocal function. Diagnostic considerations include laryngoscopy to visualize the vocal cords and assess their movement, along with imaging studies to identify underlying causes. A thorough patient history and physical examination are crucial for accurate diagnosis and management planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity: Requires specialized examination and potential imaging.
  • Treatment complexity: May involve multidisciplinary approaches including ENT specialists and speech therapists.
  • Documentation requirements: Detailed clinical notes and diagnostic findings are essential.
  • Coding specificity: Requires precise documentation to differentiate from other laryngeal conditions.

Audit Risk Factors

  • Common coding errors: Misclassification with other laryngeal disorders.
  • Documentation gaps: Incomplete records regarding the cause and severity of paralysis.
  • Billing challenges: Potential denials if documentation does not support the diagnosis.

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Speech-Language Pathology

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Related CPT Codes

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The clinical significance of J38.01 lies in its potential to affect communication and airway management in patients. Unilateral vocal cord paralysis can lead to increased healthcare utilization due to the need for specialist consultations, voice therapy, and possible surgical interventions. Understanding the epidemiology of this condition is crucial, as it may be associated with various underlying health issues, impacting population health and quality measures in healthcare settings.

ICD-9 vs ICD-10

The clinical significance of J38.01 lies in its potential to affect communication and airway management in patients. Unilateral vocal cord paralysis can lead to increased healthcare utilization due to the need for specialist consultations, voice therapy, and possible surgical interventions. Understanding the epidemiology of this condition is crucial, as it may be associated with various underlying health issues, impacting population health and quality measures in healthcare settings.

Reimbursement & Billing Impact

Reimbursement may depend on the completeness of clinical notes, including the patient's symptoms, diagnostic tests performed, and treatment plans. Common denials may arise from insufficient documentation or failure to demonstrate medical necessity for procedures related to the condition. It is essential to ensure that all relevant information is included in the claim to avoid delays in payment.

Resources

Clinical References

  • •
    ICD-10 Official Guidelines for J00-J99
  • •
    Clinical Documentation Requirements

Coding & Billing References

  • •
    ICD-10 Official Guidelines for J00-J99
  • •
    Clinical Documentation Requirements

Frequently Asked Questions

What specific conditions are covered by J38.01?

J38.01 specifically covers unilateral paralysis of the vocal cords, which may arise from conditions such as stroke, trauma, or surgical intervention affecting the recurrent laryngeal nerve.

When should J38.01 be used instead of related codes?

J38.01 should be used when there is confirmed unilateral paralysis of the vocal cords, as opposed to J38.00, which is for unspecified paralysis. Accurate diagnosis is key to appropriate code selection.

What documentation supports J38.01?

Documentation should include results from laryngoscopy, patient history detailing onset and symptoms, and any imaging studies that support the diagnosis of unilateral vocal cord paralysis.