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This blog focuses on the correct coding of slurred speech and the coding of R47.1 and related codes, including the documentation and coding sequence rules. It discusses distinguishing symptoms from diagnoses, using clinical information, and avoiding some of the common coding mistakes such as overcoding and coding the wrong condition. Coding correctly helps to ensure compliance, reimbursement, and the validity of the clinical data being reported.
Slurred speech is one of the many clinical manifestations that can be seen in many clinical settings. It may be due to a temporal, benign issue or may signify a serious brain emergency like a stroke. Coding and billing issues arise from the fact that, in most cases, speech issues are not a diagnosis, but rather a symptom. Coding challenges in this case are due to a lack of adequate physician notes, a physician’s misdiagnosis, improper coding for the provided procedures, and lack of understanding of the coding process to follow the required coding structure. These problems may result in delays or denials of payment. Strategies to code slurred speech, the requirements documenting the physician’s decision-making process and the possible coding problems that can arise are the primary objectives of this blog.
Slurred Speech in Clinical Terms
Dysarthria, or slurred speech, represents a motor speech disorder that stems from muscular weakness, paralysis, or lack of coordination of speech muscles. While aphasia also affects speech, it is due to a breakdown in the ability to process language rather than a breakdown in control of the muscles. Causes of dysarthria include event-related brain damage (such as stroke or traumatic brain injury), neurodegenerative diseases, MS, certain infections, some medications, or metabolic imbalances. Because slurred speech is an indicator of some other disorder, it is incumbent on the coder to determine whether the provider has described it as a symptom, a disorder, or as a part of some other disorder of the nervous system. That determination is critical in choosing and sequencing the codes.
Primary ICD-1O Code for Slurred Speech
The existing ICD-10 code for the most prevalent case of slurred speech is R47.1 (Dysarthria and anarthria). This is under Chapter 18 of the ICD-10-CM code set, which contains the classifications for all the symptoms, signs, and abnormal clinical/laboratory findings which do not have a specific coding. R47.1 is considered valid coding when the provider mentions dysarthric speech, slurred speech, or speech that is articulated poorly without providing a specific alternate diagnosis.
In the scenario whereby the documentation contains slurred speech without providing other explanatory factors, R47.1 becomes one of the code options. In other instances, the documentation for coding provides an alternate diagnosis, and the speech impairment is a confirmed one. Such coding can no longer accommodate the use of the symptom code.
Potentially Relevant ICD-10 Codes
Numerous ICD-10 codes can be applicable based on each unique clinical case. For instance, R47.01 (Aphasia) can be applied when there are documented impairments to the patient’s language and not only to the motor speech. With respect to documented cases of speech that is “slurred” and where the term “dysarthria” is not used, **R47.81** (Slurred speech) can be applied, as it is a code that is more specific within the R47 category. Neurology codes, for example, **I63.-** (Cerebral infarction), which is applicable in the case of an ischemic stroke, or **G35** (Multiple sclerosis), can be prioritized when they account for a symptom. **R29.818** (Other symptoms and signs involving the nervous system) can also be applied when the case documentation is not very specific, but it is suggestive of something that is neurological in nature.
Symptom Coding Versus Definitive Diagnosis Coding
One of the most crucial aspects of coding is deciding whether to code slurred speech as a symptom or as a condition. Per the ICD-10-CM guidelines, signs and symptoms that are a part of a confirmed diagnosis should not be captured separately. This is the case for an insurance claim for an acute ischemic stroke with associated slurred speech: the provider notes the stroke and there is no associated claim for R47.1. However, if the provider has slurred speech as a chief complaint, and no definitive diagnosis is available after the visit, then reporting the symptom is pertinent. This is the case to maintain compliance and avoid the risk of coding more than is necessary.
Documentation Requirements
Quality documentation is the most important step for coding the slurred speech. Providers should specify if the patient has, for example, dysarthria, slurred speech, aphasia, or some other speech problem. Details are also required for the onset, duration, and severity, as well as symptoms such as facial droop, weakness of the limbs, or an altered state of consciousness. It is also helpful for the providers to record suspected or confirmed causes. This is what coders need to clarify whether a symptom code should be utilized or a definitive diagnosis code, as well as the most specific level available for the ICD-10.
Importance of Clinical Context
Clinical context is key in choosing the right codes. For example, in the emergency department, acute onset of slurred speech and new neurologic deficits is likely to be a stroke. In contrast, slurred speech, and the patient is taking sedating medication, may be due to a drug effect. In rehabilitative care, slurred speech may be a symptom of a chronic neurological disorder, such as Parkinson’s disease. Coders analyze the entire medical record, including the assessments and the provider’s impressions and plans to discern the context of the symptom. Coding from annotations in the record without understanding the medical context is a major contributor to mistakes, and hence, undercoding and overcoding.
Coding Guidelines
In the absence of a definitive diagnosis, one of the slurred speech codes (R47.1 or R47.81) may be sequenced as the principal diagnosis if the visit is due exclusively to slurred speech. However, if the visit is in order to evaluate and treat a stroke, traumatic brain injury, brain tumor, or one of the other underlying conditions, then the definitive diagnosis should be sequenced first. The slurred speech code may be assigned as a secondary diagnosis if it meets the reporting criteria and is not considered a necessary part of the underlying condition. Such is the case if it is not due to the underlying condition, and it explains the reason for the visit, making it clinically justifiable to bill for it.
Coding Slurred Speech in Suspected Stroke Cases
The suspected stroke cases need extra care. When the provider states, rule out stroke, or suspected stroke, and there is no final diagnosis by the end of the encounter, the coders do not apply a stroke code. Instead, they code the presenting signs and symptoms, and in this case, it would be the slurred speech, weakness, or altered mental status. If the stroke is confirmed through imaging or further assessment, then the appropriate code i63. or i61. should be used and the symptoms code should be removed. This is in compliance with ICD-10-CM cases where the diagnosis is uncertain, particularly in the outpatient care setting.
Use of Combination Codes
Due to the speech deficits that are inherent in some neurological conditions, there are combination codes. For instance, there are certain codes for cerebrovascular accidents that also mention residual speech deficits. Then, documenting such a combination code means that there is no need to report separate codes for R47. 1. This is why it is always recommended that coders search for combination codes before they break their systems to provide four separate codes, as it increases efficiency by minimizing system overload and improving the integrity of the report.
Common Errors to Avoid
A common mistake has been using R47.1 when the documentation actually indicates the presence of aphasia rather than dysarthria. Another frequent mistake involves documenting a confirmed brain pathology along with the symptom of dysarthria, when the symptom is part of the diagnosis. The symptom dysarthria may be incorrectly coded by the encoders when it is mentioned in the nursing notes, and there is no physician documentation to support it. Denials and issues of compliance can also arise from using too many vague codes, as well as codes that document only symptoms when a definitive diagnosis is available. Another frequent mistake is a lack of attention to detail when reading the encounter note in its entirety.
Impact on Reimbursement and Quality Reporting
There is a correlation between precise coding of dysarthria, and reimbursement, but goes beyond that. It is related to dysarthria coding, and it has an impact on quality metrics, and also on the adjustment that is made for the risk and how serious the illness is, in addition to the severity of the illness. The reporting for quality metrics, as well as the documentation and billing related to reimbursement for stroke care, depend on accurate coding to support the case mix index and the metrics for the performance. The risk coding is the first metric, and it remains the most crucial. A careful selection of codes and the order in which they are given is of great importance for both the financial side and the clinical side of reporting.
Standard Procedures for Coders
Coders are encouraged to become more familiar with provider notes, particularly the history, assessment, and the final impression. If the notes contain gaps, it is better to ask the provider directly for an explanation, rather than throw out a guess. It is equally important to familiarize oneself with the ever-changing guidelines of the ICD-10-CM and policies issued by payers. Auditing oneself on a regular basis in conjunction with education on the coding of neurological symptoms tends to decrease the error rate and improve coding in general.
Conclusion
The symptom of slurred speech is one of the most important, and more difficult, to code, and is determined by the documentation, the clinical picture, and the guidelines of the ICD-10-CM. The code R47.1 is used most frequently to code a case where slurred speech or dysarthria is documented and is used in the absence of a documented underlying condition. However, in the case of a documented underlying condition, one would code the underlying condition instead. It is important for coders to understand the documentation necessary to defend their coding and the sequencing rules in order to code correctly, achieve the proper reimbursement, and to keep the data in the system useful. Using these principles on a regular basis, coding specialists will be able to code slurred speech with ease and confidence.
Make An Appintment With A2ZFAQs
R47.1 (Dysarthria and anarthria) is used most often when a provider notes slurred speech, or dysarthria, and does not provide an explanation for it.
No. When a stroke or an acute underlying neurological diagnosis is present, slurred speech is not coded because it is considered to be part of the diagnosis.
No. nursing notes, or notes from other non-physician providers, are not the basis for coding. Coding is based on physician notes that include a diagnosis or symptom.
When it is the only diagnosis, the provider has not determined a definitive diagnosis for this encounter.
The most common error is mixing up dysarthria (speech motor problem) and aphasia (language problem) leading to the assignment of incorrect ICD-10 codes.