i have a question regarding cpt 74230: If the physician does not state in his/her documentation that the patient has "dysphagia", but during the exam patient has aspiration with thin liquid, i cannot code 507.0-aspiration pneumonitis, but can i code unspecified dysphagia 787.20, even though the term "dysphagia" is not documented in the report? For example: How would you code this procedure:
Modified barium swallow:
Indication: Feeding difficulty and mismanagement- 783.3
this study performed under supervision of speech pathologist. Radiologist has provided fluroscopy examination an interpretation.
On the upright ap view of chest obtained prior to modified barium swallow, cardiac size appears to be normal. Pulmonary vascularity is not engorged. There is no evidence of confluent infiltrates in lungs. The patient was given to swallow thin liquid, liquid of nectar consistency, liguid of honey consistency, applesauce and cookie. With first few swallows of thin liquid there has been evidence of mild to moderate penetration, without aspiration. But at the end of the study again, the patient has been given to swallow thin liquid. At this time there has been aspiration into laryngotracheal airways with mild cough reflex. with swallowing of liquid of nectar, and liguid of honey consistencies, applesauce, and cookie there has been no evidence of penetration or aspiration into larynx.
Impression:
The patient has aspirated thin liquid. Thin liquid food items .should be avoided.
Thanks for any advice.
---dysphagia bewildered