Q38.4

Clinical notes

Documentation support

General coding-documentation guidance — not a substitute for payer-specific requirements or professional coding judgment.

• •As a general rule, code to the highest level of specificity supported by the documentation in the medical record.

ICD-9-CM equivalent

Informational only — GEM mappings are approximate, not guaranteed one-to-one equivalents. Verify before use in billing.

• 75021Approximate match
• 75022Approximate match
• 75023Approximate match
• 75024Approximate match

Associated MS-DRGs

Q38.4 can serve as the principal diagnosis for these Medicare Severity Diagnosis-Related Groups.

Informational only — actual DRG assignment also depends on procedures, complications/comorbidities (CC/MCC), discharge status, and payer-specific rules not reflected here.

• DRG 011Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with MCC
• DRG 012Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with CC
• DRG 013Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy without CC/MCC
• DRG 154Other Ear, Nose, Mouth and Throat Diagnoses with MCC
• DRG 155Other Ear, Nose, Mouth and Throat Diagnoses with CC
• DRG 156Other Ear, Nose, Mouth and Throat Diagnoses without CC/MCC