AHA Coding Clinic® for ICD-9 - 2007 Issue 3; Ask the Editor

Symptoms with a Definitive Diagnosis

A patient with known squamous cell carcinoma of the larynx presented with increasing symptoms of hoarseness, dysphagia and aspiration. Diagnostic laryngoscopy with biopsy was positive for widespread laryngeal carcinoma with lymph node involvement. Surgical excision of the tumor was carried out. Because of the difficulties with swallowing and aspiration, a percutaneous endoscopic gastrostomy (PEG) was placed. According to coding guidelines, symptoms that are integral to a condition (definitive diagnosis) should not be coded separately. Should the symptoms of hoarseness and dysphagia be coded separately or are these conditions integral to the laryngeal carcinoma? What are the appropriate diagnosis codes? ...

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