Code Description

ICD-10 R48.0 is a billable code used to indicate a diagnosis of dyslexia and alexia.

Key Diagnostic Point:

Dyslexia and alexia are specific learning disabilities that affect reading and language processing. Dyslexia is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. Individuals with dyslexia may struggle with phonological processing, which can lead to challenges in reading comprehension and written expression. Alexia, often resulting from brain injury or neurological conditions, refers to the loss of the ability to read despite having the ability to write and speak. Symptoms may include difficulty recognizing words, slow reading speed, and challenges in understanding written text. Both conditions can significantly impact academic performance and daily functioning, necessitating early diagnosis and intervention. Clinical assessment often involves standardized reading tests, neuropsychological evaluations, and assessments of language processing abilities to differentiate between dyslexia, alexia, and other related disorders.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Variability in symptom presentation among patients
Need for comprehensive neuropsychological testing
Differentiation from other learning disabilities
Potential overlap with other neurological conditions

Audit Risk Factors

Inadequate documentation of symptoms and functional impact
Failure to differentiate between dyslexia and alexia
Misuse of codes for educational vs. medical diagnoses
Lack of supporting evidence from standardized testing

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including educational background and symptom onset.

Common Clinical Scenarios

Patients presenting with reading difficulties and associated academic struggles.

Billing Considerations

Consider comorbid conditions such as ADHD or anxiety that may complicate the diagnosis.

Emergency Medicine

Documentation Requirements

Acute assessment of neurological status and any recent head trauma.

Common Clinical Scenarios

Patients with sudden onset of reading difficulties following a head injury.

Billing Considerations

Rapid evaluation of potential neurological causes for alexia.

Coding Guidelines

Inclusion Criteria

Use R48.0 When

Follow ICD
CM guidelines for coding learning disabilities, ensuring accurate documentation of the patient's history, symptoms, and any testing results that support the diagnosis

Exclusion Criteria

Do NOT use R48.0 When

No specific exclusions found.

Related CPT Codes

96130CPT Code

Psychological testing evaluation

Clinical Scenario

Used when conducting comprehensive assessments for dyslexia.

Documentation Requirements

Detailed report of testing results and interpretation.

Specialty Considerations

Psychologists and educational specialists often perform these evaluations.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more precise coding of dyslexia and alexia, facilitating better tracking of these conditions and their impact on patient care. It emphasizes the need for thorough documentation and differentiation from other learning disabilities.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more precise coding of dyslexia and alexia, facilitating better tracking of these conditions and their impact on patient care. It emphasizes the need for thorough documentation and differentiation from other learning disabilities.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more precise coding of dyslexia and alexia, facilitating better tracking of these conditions and their impact on patient care. It emphasizes the need for thorough documentation and differentiation from other learning disabilities.

Resources

Clinical References

Coding & Billing References

Frequently Asked Questions

What is the difference between dyslexia and alexia?

Dyslexia is a developmental disorder affecting reading skills from childhood, while alexia is an acquired condition typically resulting from brain injury, affecting the ability to read despite intact language skills.