ICD 10 Coding Alert

Navigating biopsy procedures may hold the key to accuracy.

Oral hairy leukoplakia is a condition that affects immunocompromised patients, especially those who smoke, and is considered “a clinical marker of HIV disease since it has a clear prognostic value in the subsequent development of AIDS,” according to the National Center for Biotechnology Information (Source: www.ncbi.nlm.nih.gov/books/NBK554591/).

Providers will be on the lookout for markers of this condition, and coders need to know what to do, too. See if you know what to do to code this scenario.

The case: A 35-year-old female patient established to your practice reports to your provider complaining of white patches on her tongue that have been occurring periodically for several months. She has noticed these patches occurring and resolving spontaneously, and she has no discomfort from them. She also says that the lesions are now becoming slightly painful, but she doesn’t have any other signs and symptoms such as altered taste.

The provider reviews the patient’s notes, which indicated the patient was on chemotherapy for breast cancer a few months ago. She has no history of alcohol use but used to smoke two cigarette packs a day prior to treatment for breast cancer.

Upon examination, your clinician notes the presence of two lesions on the lateral border of the posterior third of the tongue.

The lesions have a folded appearance with one of the lesions bearing a slightly ulcerated surface. Your clinician also notes that the surrounding tissue appears to be normal. Since one of the lesions had an ulcerated appearance, your surgeon opts to perform a biopsy and sends the sample for histological studies.

Later, based on the biopsy results, your provider diagnoses the patient’s condition as oral hairy leukoplakia.

Report the Encounter Code

“For the biopsy, you’ll use 41105 [Biopsy of tongue; posterior one-third],” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, associate partner, Pinnacle Enterprise Risk Consulting Services LLC, in Centennial, Colorado. This would be a more appropriate code choice than 41100 (Biopsy of tongue; anterior two-thirds) or 40808 (Biopsy, vestibule of mouth) “given the location of the lesions,” Loya adds. Code 40808 would be more appropriate for a biopsy of lesions found on the lips and cheeks inside the oral cavity.

Choose the Diagnosis Code

The provider arrived at the diagnosis of hairy leukoplakia, K13.3 (Hairy leukoplakia). This code “is a direct link when using the ICD-10-CM Index and is verified the Tabular List” of the ICD-10-CM code book, Loya notes.

When Appropriate, Include These Codes, Too

Last, you need to make sure you obey the “use additional code” instructions that accompany the K13.- (Other diseases of lip and oral mucosa) codes. “You should consider use of the following codes as additional diagnoses, when applicable,” suggests Loya:

• F10.- (Alcohol related disorders)
• F17.- (Nicotine dependence)
• P96.81 (Exposure to (parental) (environmental) tobacco smoke in the perinatal period)
• Z57.31 (Occupational exposure to environmental tobacco smoke)
• Z72.0 (Tobacco use)
• Z77.22 (Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic))
• Z87.891 (Personal history of nicotine dependence)

Going back through the patient’s notes will lead you to eliminate an F10.- or F17.- code as the patient has denied a history of alcohol use and has recently given up smoking. Instead, depending on provider documentation, you will probably end up coding Z87.891 for the history of nicotine dependence.

Additionally, and also dependent on provider documentation, you may use Z85.3 (Personal history of malignant neoplasm of breast) due to the patient’s recent treatment for breast cancer. Code choice here would depend on such documented factors as the patient’s breast cancer being eradicated and the course of chemotherapy treatment being completed. And if the patient is still receiving treatment, even if it’s not radiation, you would use an active cancer code.