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Coding Normal Results Frequently Asked Questions

Many third party payers will not reimburse for audiology or speech-language pathology services when the results of an evaluation are reported simply as within normal limits. These FAQs describe how to use International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes when normal results are found and provides examples for complaints that prompt the referral. The answers are based on general coding principles and best practices, as well as guidance from the Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). Audiologists and speech-language pathologists are responsible for verifying coding and billing policies with their specific payers.

How should an audiologist or speech-language pathologist assign an ICD-10-CM code when an evaluation produces a normal result?

The signs and symptoms, chief complaint, or reason(s) for the encounter should be reported as the first-listed diagnosis. The audiologist or speech-language pathologist should also use additional codes that describe any co-existing or chronic conditions. Do not code conditions that were previously treated and no longer exist, although history codes may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

Are there official instructions on how to code when the results are normal?

The ICD-10-CM Official Guidelines for Coding and Reporting [PDF] provides a description of how to report an uncertain diagnosis based on setting.

For outpatient services, ICD-10-CM guidelines state, "Do not code diagnoses documented as 'probable,' 'suspected,' 'questionable,' 'rule out,' or 'working diagnosis' or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit."

For inpatient services (including short-term, acute, and long-term care), ICD-10-CM advises "If the diagnosis documented at the time of discharge is qualified as 'probable,' 'suspected,' 'likely,' 'questionable,' 'possible,' or 'still to be ruled out' or other similar terms indicating uncertainty, code the condition as if it existed or was established.'"

Can you provide examples of how a speech-language pathologist should code signs and symptoms when results are normal?

The following chart presents examples of patients who present with specific complaints but are found to be within normal limits after an evaluation is completed.

Patient Complaint ICD-10-CM Code
Hoarse vocal quality R49.0 Dysphonia, hoarseness
Problems with swallowing R13.10 Dysphagia, unspecified
Unintelligible speech F80.0 Phonological disorder, functional speech articulation disorder
Late talker R62.0 Delayed milestones in childhood

Can you provide examples of how an audiologist should code signs and symptoms when results are normal?

The following chart presents examples of patients who present with specific complaints but are found to be within normal limits after an evaluation is completed.

Patient Complaint ICD-10-CM Code
Mild hearing loss H91.90 Unspecified hearing loss, unspecified ear
Dizziness R42 Dizziness and giddiness, light headedness, vertigo NOS
History of noise exposure H83.3X9 Noise effects on inner ear, unspecified ear

Where can I obtain a list of the ICD-9-CM codes for audiologists and speech-language pathologists?

Audiology and speech-language pathology specific ICD-10-CM lists are available on ASHA's ICD-10 website. For comprehensive speech and hearing related ICD-10 and CPT (Current Procedural Terminology) coding information, we also recommend ASHA's Coding and Billing for Audiology and Speech-Language Pathology, which is updated annually and is available for purchase on ASHA's online store.

Questions about coding can be sent to [email protected].

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