# What ICD-9 code should I code for this report? - mandibular canal



## she803 (May 20, 2011)

Examination: CT mandible without contrast 

Indication: Evaluate right inferior alveolar nerve canal 

Technique: Axial CT scanning of the mandible was performed at the administration of intravenous contrast on 5/12/2011. Multiplanar reformatting was performed. 

Findings: 

There are no fracture. The temporomandibular joints are well located. There are mild degenerative changes of the right mandibular condyle characterized by the mandibular condyles are normally located within the glenoid fossa. There are mild degenerative changes of the right mandibular condyle characterized by subchondral cyst formation and sclerosis. 

The tooth socket for the first right mandibular molar tooth is empty. The inferior margin of the empty tooth socket is directly adjacent to the superior margin of the inferior mandibular canal, the intervening bone is dehiscent. 

Impression: 

The inferior margin of the empty right first mandibular molar tooth socket abuts the superior margin of the right mandibular canal, with dehiscence of the intervening bone (image 14-15 series 338).

Thank you,

Salima H., CPC

Radiology Coding Specialist


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