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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 questions and answers describe how to use International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes when normal results are found and provides examples for major communication and related complaints that prompt the referral.

What if a speech-language pathologist or audiologist performs diagnostic testing that produces a normal result?

The signs and symptoms, chief complaint, or reason(s) for the encounter should be reported as the primary 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 any instructions available on how to code when the results of an audiology or a speech-language assessment are normal?

The ICD-9-CM Official Guidelines for Coding and Reporting became effective on October 1, 2003. A description of how to report an uncertain diagnosis is found on page 48: "If the diagnosis documented at the time of discharge is qualified as 'probable', 'suspected', 'likely', 'questionable', 'possible', or 'still to be ruled out', code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis." The Official Guidelines are available on the Centers for Disease Control and Prevention Web site [PDF].

Has Medicare issued any instructions?

The Centers for Medicare & Medicaid Services (CMS) issued ICD-9-CM Coding Guidelines for Diagnostic Tests in a Program Memorandum dated September 26, 2001 (Transmittal AB-01-144, Change Request 1724). This PM (now §10.1 of Chapter 23 of Medicare Claims Manual) directs practitioners to report diagnoses based on test results. In Section B., Instructions to Determine the Reason for the Test, CMS states that the Balanced Budget Act (BBA) required referring physicians to provide diagnostic information to the testing entity at the time the test is ordered. All diagnostic tests paid by CMS must be ordered by the physician who is treating the beneficiary. If the physician does not provide diagnostic information, and is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient's medical record. However, an attempt should be made to confirm any information obtained by the patient by contacting the referring physician.

Can you provide examples of signs and symptoms for voice disorders?

Complaint ICD-9-CM Code
Hoarse/breathy/harsh voice 784.42 Dysphonia, hoarseness
High pitch; low pitch 784.49 Other voice and resonance disorders, change in voice
Problems with voice production 784.40 Voice and resonance disorder, unspecified OR
784.41 Aphonia, loss of voice
Nasal/denasal voice 784.43 Hypernasality
784.44 Hyponasality

Can you provide examples of signs and symptoms for swallowing disorders?

Complaint ICD-9-CM Code
History of aspiration or aspiration pneumonia 507.0 Pneumonitis due to inhalation of food or vomit
Problems with swallowing, oral phase 787.21 Dysphagia, oral phase
Problems with swallowing, pharyngeal phase 787.23 Dysphagia, pharyngeal phase
Cough 786.2 Cough
Esophageal reflux 530.81
Facial weakness 781.94 Facial weakness
Feeding difficulty 783.3 Feeding difficulties and mismanagement

Can you provide examples of signs or symptoms associated with aphasia of other expressive/receptive language disorders?

Complaint ICD-9-CM Code
Difficulty speaking 784.51 Dysarthria
Unintelligible speech 784.51
Difficulty understanding spoken language 784.3 Aphasia
Difficulty understanding written language 784.61 Alexia and dyslexia: Alexia (with agraphia)
Difficulty reading/writing 784.61
Difficulty remembering words 784.3 or 310.8 Mild memory disturbance due to organic brain damage
Difficulty expressing thoughts 784.3 or 310.8
Difficulty processing information 784.3
Difficulty following directions 784.3
Difficulty remembering tasks 310.1 or 310.8
Cognitive deficits 784.60 Symbolic dysfunction, unspecified
Word retrieval difficulties 784.3
Difficulty with word meaning 784.3

Do you have other examples of signs and symptoms that will be useful to audiologists?

Complaint ICD-9-CM Code
Unspecified hearing loss 389.9 Unspecified hearing loss
Tinnitus 388.30 Tinnitus
Vertigo 780.4 Vertigo
Dizziness 780.4 Dizziness and giddiness
Ear pain 388.70 Otalgia, unspecified
Aural fullness 388.8 Other disorders of the ear
Discharging ear 388.60 Otorrhea, unspecified
Delayed speech and language development 315.31 Expressive language disorder OR
783.42 Late talker
Articulation errors 315.39 Developmental articulation disorder OR
Unintelligible speech 315. 39 or 783.42
Difficulty hearing in noise 389.9
Acoustic trauma 388.11 Acoustic trauma (explosive) to ear
Facial weakness 781.94 Facial weakness, Facial droop
Facial numbness 782.0 Disturbance of skin sensation
History of tympanic membrane perforation 384.20 Perforation of the tympanic membrane, unspecified
History of noise exposure 388.10 Noice effects on inner ear, unspecified

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

You may access a list of ICD-9-CM codes online [PDF]. For comprehensive speech and hearing related ICD-9 and CPT coding information, we recommend the Health Plan Coding and Claims Guide. The complete ICD-9-CM is available in medical libraries, medical center billing offices, or may be purchased online.

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