Dysphagia, unspecified
ICD-10 R13.10 is a billable code used to indicate a diagnosis of dysphagia, unspecified.
Dysphagia, or difficulty swallowing, is a clinical symptom that can arise from various underlying conditions affecting the esophagus, throat, or neurological function. Patients may experience discomfort or pain while swallowing, a sensation of food getting stuck, or the inability to swallow altogether. This condition can lead to significant complications, including malnutrition, dehydration, and aspiration pneumonia. Dysphagia can be classified into oropharyngeal dysphagia, which involves difficulty initiating swallowing due to problems in the throat or esophagus, and esophageal dysphagia, which occurs when there is an obstruction or motility disorder in the esophagus. The unspecified nature of this code indicates that the specific cause of dysphagia has not been determined, necessitating further investigation. Common causes include neurological disorders (e.g., stroke, Parkinson's disease), structural abnormalities (e.g., tumors, strictures), and muscular disorders (e.g., myasthenia gravis). A thorough clinical evaluation, including a detailed history, physical examination, and possibly imaging studies or endoscopy, is essential for diagnosis and management.
Detailed history of swallowing difficulties, associated symptoms, and any relevant medical history.
Patients presenting with unexplained weight loss, recurrent aspiration pneumonia, or chronic cough.
Consideration of comorbidities that may contribute to dysphagia, such as GERD or neurological disorders.
Acute assessment of swallowing difficulties, including vital signs and any immediate interventions.
Patients presenting with acute onset of dysphagia following a stroke or foreign body ingestion.
Rapid assessment and documentation are crucial to determine the need for emergent interventions.
Used when assessing a patient with dysphagia for treatment planning.
Document the patient's swallowing difficulties, assessment findings, and any interventions planned.
Speech-language pathologists may perform this evaluation in collaboration with physicians.
Document the patient's history of swallowing difficulties, any associated symptoms, and the results of any diagnostic tests performed. Ensure that the clinical rationale for the diagnosis is clear.
