🧬 ICD-10 CM I69.191 — Dysphagia Following Nontraumatic Intracerebral Hemorrhage
Billable Code Confirmed
ICD-10 CM I69.191 is a complete 6-character code, the deepest level the tabular list defines for this presentation, identifying dysphagia specifically among the “other sequelae” grouped under I69.19 alongside apraxia, facial weakness, and ataxia. Unlike the cognitive-deficit or hemiplegia branches of this family, this single code covers dysphagia regardless of severity, and the code carries its own instructional note directing you to add a phase-specific R13.1x code when the documentation supports it. It’s also POA Exempt, consistent with the rest of the I69 sequela category, since it represents a persisting residual rather than something newly developing during the current encounter.
Non-Billable Parent Codes
I69.19, Other sequelae of nontraumatic intracerebral hemorrhage, is the immediate non-billable parent — it groups dysphagia together with apraxia, facial weakness, and ataxia under one category header but doesn’t identify which specific deficit the patient has, so it cannot be submitted alone. I69.1, Sequelae of nontraumatic intracerebral hemorrhage, is the broader non-billable category spanning all deficit types following this stroke subtype — cognitive, speech, monoplegia, hemiplegia, and this “other” grouping — and fails for the same lack-of-specificity reason. I69, Sequelae of cerebrovascular disease, sits at the top as the non-billable category covering all stroke subtypes’ sequelae, and doesn’t identify either the hemorrhagic cause or the dysphagia deficit on its own.
Clinical Context
ICD-10 CM I69.191 applies once the acute intracerebral hemorrhage has resolved and swallowing difficulty persists as a residual finding, with no time limit on how long after the original event this can still apply. The single most important coding detail specific to this code is its own instructional note: when the phase of dysphagia is known — oral, oropharyngeal, pharyngeal, or pharyngoesophageal — an additional code from R13.11 through R13.19 should be added, with I69.191 sequenced first and the R13.1x phase code second. This isn’t a formal etiology/manifestation pair in the strict ICD-10-CM sense (R13.1x codes don’t carry “in diseases classified elsewhere” titles), but the reciprocal Use Additional and Code First notes between the two categories make the intended sequencing clear. A bare, unspecified R13.10 generally adds nothing once I69.191 is already documented, so the additional code is most valuable when a swallow study or SLP evaluation actually identifies a specific phase.
Code Classification
ICD-10 CM I69.191 is a diagnosis code, not a procedure code, describing a residual functional deficit rather than an active disease process. It commonly appears as a secondary diagnosis on PM&R rehab admissions and OTO/ENT consults, and occasionally drives its own workup when aspiration risk or nutritional status becomes the primary clinical concern.
🔍 Code Description
ICD-10 CM I69.191 captures swallowing dysfunction that persists as a residual finding after a nontraumatic intracerebral hemorrhage has run its acute course, sitting within the I69.19 “other sequelae” grouping alongside I69.190 (apraxia), I69.192 (facial weakness), and I69.193 (ataxia) — a catch-all category for deficit types that don’t fit the cognitive, speech-and-language, monoplegia, or hemiplegia branches elsewhere in I69.1. Unlike those other branches, this code doesn’t subdivide by laterality or severity; one code covers the full spectrum of post-hemorrhagic swallowing impairment, with the phase-specific detail captured instead through the companion R13.1x code when a formal swallow evaluation has identified it. Post-stroke dysphagia is clinically significant well beyond the swallowing difficulty itself, since it’s a major driver of aspiration pneumonia risk, malnutrition, and dehydration in the stroke recovery population, which is part of why accurate capture matters even though it carries no CMS-HCC weight.
This code’s most important practical distinction is from its near-identical sibling I69.391, which describes the same dysphagia presentation but attributes it to a prior cerebral infarction rather than intracerebral hemorrhage — exactly the same coordination challenge that exists for the hemiplegia branch of this family, where getting the causal stroke subtype right requires confirming the original event, not just the current symptom. It’s also worth distinguishing from a standalone R13.10 dysphagia code used without any I69 sequela code; once a cerebrovascular cause is established and documented, the R13.1x code should not stand alone as the only diagnosis, since the official guidelines treat symptom codes like this as secondary once a definitive underlying diagnosis exists. In your OTO and PM&R inpatient work, this code typically surfaces either as the reason for an SLP/swallow evaluation consult or as a significant secondary diagnosis shaping diet orders and aspiration precautions on an unrelated surgical or rehab stay.
🌳 Code Tree / Hierarchy
I69 Sequelae of cerebrovascular disease ❌ Non-billable
│
├── I69.1 Sequelae of nontraumatic intracerebral hemorrhage ❌ Non-billable
│ │
│ ├── I69.10 Unspecified sequelae of nontraumatic intracerebral hemorrhage ✅ Billable
│ ├── I69.15 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage ❌ Non-billable
│ │ └── I69.151 ...affecting right dominant side ✅ Billable
│ │
│ ├── I69.19 Other sequelae of nontraumatic intracerebral hemorrhage ❌ Non-billable
│ │ │
│ │ ├── I69.190 Apraxia following nontraumatic intracerebral hemorrhage ✅ Billable
│ │ ├── I69.191 Dysphagia following nontraumatic intracerebral hemorrhage ◀ THIS CODE ✅ Billable
│ │ └── I69.198 Other sequelae of nontraumatic intracerebral hemorrhage ✅ Billable
│ │
│ └── I69.12 Speech and language deficits following nontraumatic intracerebral hemorrhage ❌ Non-billable
│
└── I69.3 Sequelae of cerebral infarction ❌ Non-billable (parallel family — same deficit structure, ischemic rather than hemorrhagic cause)
The Reciprocal Use Additional / Code First Pair
ICD-10 CM I69.191 says “use additional code R13.11-R13.19 if known,” and R13.1 itself says “code first dysphagia following cerebrovascular disease (I69.-) if applicable” — these two instructions point at each other, confirming I69.191 sequences first with the phase-specific R13.1x code following it, never the reverse.
Tip
✅ Includes
Difficulty swallowing documented as a late effect of a completed nontraumatic intracerebral hemorrhage, regardless of how much time has passed since the original event. Swallowing dysfunction identified through bedside screening, clinical swallow evaluation, or instrumental studies like videofluoroscopy or fiberoptic endoscopic evaluation. Encounters for ongoing SLP treatment, diet texture modification, or aspiration precaution management addressing this residual deficit. Multiple coding with a phase-specific R13.1x code when a formal swallow evaluation has characterized the dysphagia as oral, oropharyngeal, pharyngeal, or pharyngoesophageal. Cases where the dysphagia is the primary reason for an OTO or SLP consult on an otherwise unrelated inpatient stay.
❌ Excludes
Excludes 1
ICD-10 CM Z86.73, personal history of cerebral infarction without residual deficit (also covering PRIND and RIND history), is mutually exclusive because that code specifically signals the absence of any residual deficit, while I69.191 signals an active, ongoing swallowing impairment — a chart can’t simultaneously claim no residuals and document persistent dysphagia from the same event. S06.-, sequelae of traumatic intracranial injury, is mutually exclusive because category I69 is reserved for sequelae of the nontraumatic cerebrovascular conditions in I60-I67; dysphagia following a traumatic brain injury must be coded through S06 with the seventh character “S” instead.
Danger
The most common Excludes1-adjacent error here isn’t the formal exclusion itself but Z86.73 overuse — coding “history of stroke, no residual deficits” when the chart actually documents ongoing dysphagia is a frequently cited audit finding, since it understates the patient’s actual clinical picture and misses the I69.191 capture entirely.
Excludes 2
G45.-, transient cerebral ischemic attacks and related syndromes, is not part of the I69.191 concept, but both can be coded together when clinically supported — a patient with an old, completed intracerebral hemorrhage and persistent dysphagia (I69.191) can separately experience a new TIA being worked up during the same admission, with both conditions captured.
📋 Clinical Overview
When to Add the Phase Code, and Which Stroke-Subtype Branch Applies
Getting this code right involves two separate decisions: confirming the causal stroke subtype was hemorrhagic rather than ischemic, and determining whether the documentation supports adding a phase-specific R13.1x code on top of I69.191 itself.
| Feature | I69.191 | I69.391 | R13.10 (standalone) |
|---|---|---|---|
| Causal event | Documented prior nontraumatic intracerebral hemorrhage. | Documented prior cerebral infarction (ischemic stroke) — identical symptom, different cause. | No documented cerebrovascular cause, or cause not yet established. |
| Sequencing role | Sequenced first; pair with R13.1x phase code when known. | Sequenced first; pair with R13.1x phase code when known. | Used alone, or as principal when the underlying cause genuinely isn’t yet identified. |
| When each applies | History confirms intracerebral hemorrhage as the original event. | History confirms cerebral infarction as the original event. | Acute or new-onset dysphagia being worked up before a cause is confirmed, or dysphagia from a non-stroke cause. |
CDI Trigger
If a swallow evaluation note specifies “oropharyngeal phase” or “pharyngeal phase” dysphagia but the diagnosis list only carries I69.191 without an R13.1x add-on, that’s a query trigger — the phase detail is sitting in the SLP note and should be captured with the additional code rather than left off the final code list.
Manifestations & Symptom Burden
Coughing, choking, or throat clearing during meals, often the first clinical sign prompting a swallow evaluation. Reduced oral intake or unintentional weight loss when dysphagia goes unaddressed over time. Recurrent aspiration pneumonia is one of the most clinically significant downstream consequences and should be separately coded when documented as its own complication. Pocketing of food in the cheek or prolonged chewing time can indicate oral-phase involvement specifically. Wet or gurgly vocal quality after swallowing is a frequently cited bedside sign of penetration or aspiration risk.
Tip
Don’t code the individual symptoms (coughing with meals, choking) separately when they’re simply part of the dysphagia presentation — code the I69.191 sequela itself, add the phase code if known, and separately capture any resulting complication like aspiration pneumonia if it’s documented as its own condition.
💰 HCC Risk Adjustment
| Model | HCC Status |
|---|---|
| CMS-HCC V24 | Not mapped |
| CMS-HCC V28 | Not mapped |
| HHS-HCC (ACA marketplace) | HHS-HCC 151 — Sequelae of Cerebrovascular Disease |
| RAF Impact (Medicare Advantage) | None |
ICD-10 CM I69.191 sits outside both CMS-HCC models entirely — the parallel cerebral infarction code I69.391 is explicitly documented as carrying no CMS-HCC weight, and the same holds here, in contrast to the hemiplegia/hemiparesis branch of this same family which does carry weight under HCC 103. If you’re working a commercial ACA marketplace chart rather than a Medicare Advantage chart, this code does carry weight under the separate HHS-HCC model’s broader Sequelae of Cerebrovascular Disease category, so the same code behaves differently depending on which payer’s risk-adjustment model actually applies. There’s no annual recapture pressure or RAF-driven query incentive here under CMS-HCC specifically, so don’t treat this the same way you’d treat the hemiplegia code from the same family. Clinical and CDI value remains real regardless of HCC status, since accurate dysphagia capture drives diet orders, aspiration precautions, and medical necessity documentation for SLP services.
🏥 MS-DRG Assignment
| Scenario | DRG | MDC |
|---|---|---|
| Principal diagnosis, general acute care hospital | DRG 056 (with MCC) or DRG 057 (without MCC) | MDC 1 |
| Secondary diagnosis on an unrelated stay | No DRG impact on its own | N/A |
When I69.191 is sequenced as principal diagnosis, it groups to the same DRG 056/057 pair under MDC 1 as the rest of the I69.1 sequela family, with the familiar two-tier MCC split rather than a three-tier CC/MCC structure. In practice, dysphagia alone rarely drives an inpatient admission as principal diagnosis — far more commonly, it’s a secondary diagnosis on a chart where the actual admission is for aspiration pneumonia, a PM&R rehab stay, or an unrelated surgical procedure where swallowing status affects medication administration and diet orders. The most consequential coding pitfall here is failing to also capture aspiration pneumonia as a separate, codeable complication when it’s documented — that complication, not the dysphagia itself, is usually what actually drives MCC status and DRG weight on these charts. Confirm whether the encounter is occurring while the original hemorrhage is still in its acute phase versus genuinely resolved with only the residual remaining, since that distinction determines whether I69.191 is even the correct code to use yet.
🔗 Related ICD-10-CM Codes
I69.19x sibling “other sequelae” types: I69.190 (apraxia), I69.192 (facial weakness), I69.193 (ataxia), I69.198 (other sequelae, not elsewhere specified).
Parallel dysphagia-following-stroke families by subtype, and companion phase codes: I69.391 (same deficit, following cerebral infarction), I69.091 (same deficit, following nontraumatic subarachnoid hemorrhage), R13.12 (oropharyngeal phase, companion code), R13.13 (pharyngeal phase, companion code).
🛠️ Commonly Associated CPT Codes
92610 — Evaluation of oral and pharyngeal swallowing function. The core clinical swallow evaluation code, typically the starting point once dysphagia is suspected.
92611 — Motion fluoroscopic evaluation of swallowing function by cine or video recording. The modified barium swallow study (MBSS), used to visualize the swallow mechanism directly.
92612 — Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording (FEES). An alternative instrumental study to MBSS, often preferred when radiation exposure or portability is a concern.
92526 — Treatment of swallowing dysfunction and/or oral function for feeding. The treatment code following evaluation, used for ongoing SLP swallowing therapy sessions.
99221-99223 — Initial hospital inpatient E/M, used when an OTO physician or physiatrist performs the admitting evaluation that identifies the dysphagia.
99231-99233 — Subsequent hospital inpatient E/M, used for ongoing physician oversight of the swallowing management plan during the stay.
NCCI Bundling Considerations
CPT 92611 (MBSS) and 92612 (FEES) are generally not billed together for the same indication in the same encounter, since they’re alternative instrumental approaches to the same clinical question rather than complementary studies. SLP-furnished swallowing services require the -GN therapy modifier on Medicare claims, distinct from the -GP (physical therapy) and -GO (occupational therapy) modifiers used elsewhere in PM&R billing — using the wrong modifier is a common cross-specialty mix-up. The treatment code 92526 performed the same day as an evaluation code (92610, 92611, or 92612) by the same provider typically requires clear documentation that both a distinct evaluation and a distinct treatment component occurred, since payers can otherwise treat the treatment as included in the evaluation visit.
🔬 ICD-10-PCS Crosswalk
F00ZHZZ — Bedside swallowing and oral function assessment. The initial, non-instrumental screening typically performed first to identify aspiration risk.
F00ZJWZ — Instrumental swallowing and oral function assessment using swallowing equipment. Captures the facility-side procedure code for instrumental studies like FEES or videofluoroscopic evaluation.
F06ZDZZ — Swallowing dysfunction treatment. The facility-side treatment code corresponding to ongoing SLP swallowing therapy sessions during the inpatient stay.
These are facility-side ICD-10-PCS codes for the inpatient UB-04, distinct from the CPT codes your profee billing actually uses — most relevant here for CIC exam coverage of the Physical Rehabilitation and Diagnostic Audiology section’s speech/swallowing subcategories.
💊 Coding Scenarios and Examples
Scenario 1 — OTO/ENT-driven, secondary diagnosis with phase code. A patient with a prior intracerebral hemorrhage is admitted with aspiration pneumonia; ENT is consulted and performs a FEES evaluation, documenting oropharyngeal phase dysphagia as the underlying cause.
Codes: principal diagnosis is the aspiration pneumonia, with I69.191 and R13.12 (oropharyngeal phase) sequenced as secondary diagnoses, plus 92612 for the FEES procedure itself. Sequencing note: I69.191 comes before R13.12 per the reciprocal Use Additional/Code First convention, and the aspiration pneumonia — not the dysphagia — is what’s actually driving the principal diagnosis and DRG here.
Scenario 2 — PM&R inpatient rehab, secondary diagnosis. A patient admitted to an inpatient rehabilitation facility for residual weakness following a prior intracerebral hemorrhage also has a documented bedside swallow screen showing pharyngeal phase dysphagia; SLP initiates a modified diet and swallowing therapy.
Codes: the rehab-qualifying motor deficit remains principal, with I69.191 and R13.13 (pharyngeal phase) added as secondary diagnoses, alongside F00ZHZZ and F06ZDZZ on the facility side. CDI note: SLP documentation alone is generally sufficient to support the phase-specific code when there’s a provider attestation linking it back to the cerebrovascular event.
Scenario 3 — Urology inpatient, secondary diagnosis affecting care plan. A patient is admitted for an elective urologic procedure; the history notes a prior intracerebral hemorrhage with known, longstanding dysphagia requiring thickened liquids and crushed medications.
Codes: principal diagnosis is the urologic condition necessitating the admission, with I69.191 sequenced as a secondary diagnosis explaining the modified medication administration route and diet order. Sequencing note: no phase code is added here since the documentation doesn’t specify a phase, just a known, established dysphagia affecting the care plan for an unrelated admission.
⚠️ Coding Pitfalls and Tips
Don’t let I69.191 sit alone when the SLP note actually specifies a phase — add the appropriate R13.11-R13.19 code, since the chart’s own instructional notes point both directions and the additional specificity is often sitting unused in the swallow evaluation.
Watch for Z86.73 overuse on stroke history charts — if dysphagia, hemiparesis, or cognitive deficits are documented as ongoing, the correct code is the relevant I69 sequela, not a “without residual deficit” history code, and this mismatch is a frequently cited audit finding.
Remember this code carries no CMS-HCC weight, unlike its hemiplegia sibling in the same I69.1 family — don’t apply the same annual-recapture urgency you would for I69.151 when working a Medicare Advantage chart, though commercial ACA marketplace plans under the HHS-HCC model are a different story.
Confirm the causal stroke subtype before coding — I69.191 (hemorrhagic) and I69.391 (ischemic) describe an identical clinical symptom but require different category selection based on the documented mechanism of the original event.
Look for the actual complication driving DRG weight on these charts — aspiration pneumonia, not the dysphagia diagnosis itself, is usually the real MCC, so don’t stop at I69.191 if a downstream pulmonary complication is also documented and codeable.
Use the -GN therapy modifier for SLP-furnished swallowing services, not -GP or -GO — this is one of the more common modifier mix-ups when dysphagia coding crosses paths with -PT/-OT billing on the same rehab chart.