Oncology & Hematology Coding Alert

Here are some basic features of hairy leukoplakia that you can bank upon when reading the clinical documentation:

• Hairy leukoplakia is usually a painless plaque along the lateral border of the tongue. These white patches will usually be asymptomatic with no pain and many a times your clinician will discover them during routine examination.
• The plaques may also be found on the ventral or the dorsal surface of tongue and even in the buccal mucosa
• Some patients do complain of pain and changes to taste sensations.
• Edema or erythema in the adjacent areas may typically be absent, except in the case of a superimposed infection.
• The lesions may resolve spontaneously, but newer lesions keep occurring at periodic intervals.
• Your clinician may document a history HIV or an immunocompromised state due to some other systematic conditions.
• If your clinician tries to scrape out the lesion, he might note that the lesion cannot be detached easily and only the topmost layer of the lesion could be removed.

Making the diagnosis: In most cases, your clinician will identify the diagnosis to be “oral hairy leukoplakia” based on history, signs and symptoms, and on the observations of clinical examination. Based on necessity, your clinician might opt to undertake a biopsy and histological studies to help confirm the diagnosis and to differentiate the condition from other conditions that have a similar appearance. Your clinician will definitely opt for a biopsy if the lesions are ulcerated or have an appearance that is suggestive of cancer.

Apart from findings suggestive of hairy leukoplakia through histological studies, your clinician might also opt to check for the presence of Epstein-Barr virus (EBV) within the lesion’s epithelial cells to help confirm the diagnosis of oral hairy leukoplakia.