Oral Surgery Coding & Reimbursement Alert

Hint: Check CCI when reporting two codes together.

When your oral surgeon performs an incision and drainage (I&D) of a cyst, hematoma or an abscess in the floor of the mouth, you will need to identify the approach your clinician used and the anatomical site of the lesion to arrive at the right code to report for the procedure.

Opt for Different Code Sets Based on Surgical Approach

Understanding the clinical reasons for intraoral and extraoral approaches can make your code selection for the I&D procedure easier. Your maxillofacial surgeon typically uses an intraoral approach for lesions present on the tongue or in the sublingual space. 

For lesions present in the submental space or the submandibular spaces, your clinician might opt to use an extraoral approach. Understanding that “dentistry is not a covered service in Medicare, and that Medicare is the basis for all insurance standards, it is imperative that the clinician document the anatomical structures involved in the I&D,” advises Barry Shipman, DMD, clinical professor, University of Florida School of Dentistry,  Hialeah Dental Center. “The anatomical etiology of the problem and the E/M diagnosis will help you determine if your surgeon used the intraoral or extraoral approach.”

So, depending on the approach that your surgeon uses to perform an incision and drainage of a cyst, hematoma or an abscess in the floor of the mouth, you’ll use the following code ranges:

• Intraoral: 41000-41009
• Extraoral: 41015-41018 

Watch Anatomical Location to Report Accurate I&D Codes

When your oral surgeon performs an incision and drainage through an intraoral approach, you will need to report one of the six codes from the range 41000-41009, depending on where the lesion or abscess is. The six code choices that you have, depending on the anatomical location of cyst, hematoma or abscess include:

• 41000 (Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual)
• 41005 (…sublingual, superficial)
• 41006 (…sublingual, deep, supramylohyoid)
• 41007 (…submental space)
• 41008 (…submandibular space)
• 41009 (…masticator space)

Example: Your maxillofacial surgeon reviews a 65-year-old male patient with complaints of marked swelling in the floor of the mouth with dysphagia. Upon examination, your clinician notes that the patient had a significant swelling of the floor of the mouth involving the sublingual area. The patient had no signs of symptoms of any kind of respiratory distress. The patient had a past history of coronary bypass and is currently on anticoagulant therapy.

Based on signs and symptoms, history and imaging studies, your surgeon makes a diagnosis of sublingual hematoma. He performs an incision and drainage procedure by accessing the sublingual area through the intraoral route.

What to report: Since your clinician performed an intraoral incision and drainage of the superficial sublingual area, you report 41005. You report the diagnosis with the ICD-9 code, 528.9 (Other and unspecified diseases of the oral soft tissues). You report this diagnosis with K13.70 (Unspecified lesions of oral mucosa) or K13.79 (Other lesions of oral mucosa) if you are using ICD-10 codes.

Exercise Caution When Reporting Two I&D Codes

Although you might not frequently encounter situations wherein you report two incision and drainage codes together, you will have to be careful when such a scenario arises (see the example below) to prevent denials. “Anatomically, the spaces run adjacent to or in close proximity to each other and are only separated by facial and tissue or muscle planes, Shipman instructs.  “As long as there is a clear differentiation of anatomical land marks, then involvement in separate planes could be appropriate,” he adds. 

Check whether the two codes can be reported together for the same patient for the same encounter. Some of these codes in the range 41000-41009 are bundled according to Correct Coding Initiative (CCI) edits.

According to the edits, you will face bundling if you are trying to report 41005 with 41006 and for codes 41008 with 41007. However, the modifier indicator for both these code bundles is ‘1,’  which means you can unbundle the two codes and report them separately if you use a suitable modifier such as 59 (Distinct procedural service). “If the involvement in one plane leads to another plane, it may not be considered separate I&D procedures which is what a 59 modifier indicates,” says Shipman. "It might be possible to have a R and L involvement and then, if documented correctly, a 59 modifier might be appropriate.”  In the first code bundle, you will have to append the modifier to 41005 and in the second instance you will use the modifier with 41008.

Caveat: You will also face some code bundling when trying to report intraoral I&D codes with extraoral I&D codes. So, watch for CCI edits if you encounter a situation wherein you are trying to report 41015 (Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual) with either 41005 or 41006. Similarly, you will face edits if you are planning on reporting 41016 (…submental) with 41007 and 41018 (…masticator space) with 41009.

Example: Your oral surgeon reviews a 45-year-old female patient with complaints of severe swelling of the face. She complains that she was experiencing some pain from a decayed third molar tooth for some days now, which had receded, and then she suddenly began to experience swelling. She also complained of some amount of trismus and dysphagia but was not having any kind of respiratory problems. She also said that she had been on antibiotic therapy for the third molar infection.

Upon examination, your clinician notes diffuse swelling present in the left submandibular and submental spaces. Since the patient had not responded well to previous antibiotic therapy, your surgeon performs an I&D. He makes separate incisions to access the submandibular and the submental areas and drains the abscess.

What to report: Since your clinician made separate incisions to access the submandibular and the submental areas, you’ll have to report 41007 for I&D of the submental area and 41008-59 for I&D of the submandibular area. You report the diagnosis with 522.5 (Periapical abscess without sinus) when reporting with ICD-9 codes or use K04.7 (Periapical abscess without sinus) when using ICD-10 codes.

Don’t Automatically Include E/M Codes

If your surgeon evaluates the patient for any complaints of dysphagia, swelling or difficulty in breathing caused due to a cyst, hematoma or an abscess of the tongue or the floor of the mouth and in the same session decides to perform an I&D, stop before you report an E/M code with CPT® codes 41000-41009.

Rationale: According to CCI edits, you are not allowed to report an established patient office or an inpatient E/M code, as these codes are bundled into the CPT® codes for intraoral incision and drainage. However, the modifier indicator for this code bundling is ‘1,’ which means you can unbundle the codes with the use of a modifier.

You cannot unbundle the codes if your surgeon evaluated the patient for the cyst, hematoma or the abscess in the floor of the mouth and then performed the I&D procedure in the same session. 

You can only unbundle the codes and report an appropriate E/M code if and only if your clinician performed a significant and separately identifiable E/M service. 

In such a case, you append the modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) with the E/M code to indicate to your payer that the E/M service was a separate service. “Modifier 25 indicates that the use of a separate E/M code that results in the decision to do surgery is inappropriate,” Shipman says.

Example: Your clinician evaluates a 65-year-old female patient with complaints of swelling in the floor of the mouth in the sublingual area coupled with dysphagia. The patient is not under any kind of respiratory distress due to the problem. Your clinician plans to perform an I&D procedure to provide relief to the patient. 

While evaluating the patient, the patient says that she has uncontrolled diabetes and has had problems with wound healing in the past. Since this issue might cause problems with healing and infection, your clinician evaluates the patient further. Since her sugar levels were in the normal range and she was on proper anti-diabetic oral medication regime, your surgeon proceeds with the I&D.

What to report: You report the I&D procedure with 41005 and the evaluation of the patient with an appropriate E/M code (such as 99202, Office or other outpatient visit for the evaluation and management of a new patient…) with the modifier 25 appended.