Oral Surgery Coding & Reimbursement Alert

Good news: You don’t have to worry a lot about these changes.

If you have had a look at the latest version of Correct Coding Initiative (CCI) edits that went into effect on April 1, you would have noticed that it includes thousands of new edit pairs that pertain to oral surgery. In short, virtually any procedure that your surgeon performs is listed in the bundles.

Tip: There are so many edits in place, it will be easier for you to learn and implement the exceptions rather than the applicable edits themselves.

Pay Attention to These Edits Involving IV Infusion Procedures

Almost every code that you will use in oral surgery is included in CCI 22.1 edits. According to these edits, these oral surgical procedure codes are considered a Column 1 code with each of these IV infusion procedures:

• +96361 – Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)
• +96366 – Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)
• +96367 – Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)
• +96368 – Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure).

Since the oral surgery codes are in Column 1, you should only report these surgical procedural code (such as 40816, Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying muscle) if performed during the same encounter as one of, the four IV infusion codes above.

Modifier indicator: Each of these above mentioned edit pairs carries a modifier indicator of “1,” meaning that you might be able to report both codes in an edit pair if you have sufficient documentation to support separate coding. If so, you should append a modifier (such as 59, Distinct procedural service) to the Column 2 code.

However, you should remember that your oral surgeon is not usually involved in providing infusions, so these edits should not cause much change to the way you report the procedures performed. But it’s still good to know about edits in the specialty even if you don’t expect to use them.

Look Out for Some Exceptions to These Edits

Although CCI 22.1 bundles the add-on IV infusion codes into virtually every oral surgery related procedure in CPT^®, you’ll still be able to report some services without the work of trying to override an edit.

The following procedures can be submitted on the same claim as the IV infusion codes without any special documentation (other than clear notes regarding the services provided):

“Unlisted” codes such as:

• 21089 (Unlisted maxillofacial prosthetic procedure)
• 21299 (Unlisted craniofacial and maxillofacial procedure)
• 21499 (Unlisted musculoskeletal procedure, head)
• 40799 (Unlisted procedure, lips)
• 40899 (Unlisted procedure, vestibule of mouth)
• 41899 (Unlisted procedure, dentoalveolar structures)
• 42299 (Unlisted procedure, palate, uvula)
• 42699 (Unlisted procedure, salivary glands or ducts).

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