Oral Surgery Coding & Reimbursement Alert

Understand when to report E/M codes with the drainage codes.

When reporting an extraoral incision and drainage of a cyst, abscess, or hematoma of the floor of the mouth, you will have to identify the space from which the lesion has been drained to arrive at the appropriate code for the procedure.

Choose From Different Code Sets Depending on Site of Incision

You can choose the right code for the I&D procedure by looking at the area that your surgeon wants to access and drain. 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

Your maxillofacial surgeon will typically use an extraoral approach for draining an abscess or hematoma when it is present in the submental space or the submandibular space.

Check Anatomical Location to Zero in on the Apt I&D Code

When your oral surgeon performs an incision and drainage through an extraoral approach, you will need to report one of the four codes from the range 41015-41018, depending on where the lesion or abscess is. The four code choices that you have, depending on the anatomical location of cyst, hematoma or abscess include:

• 41015 (Extraoral incision and drainage of abscess,cyst, or hematoma of floor of mouth; sublingual)
• 41016 (…submental)
• 41017 (…submandibular)
• 41018 (…masticator space)

Example: Your maxillofacial surgeon reviews a 39-yearold female patient with complaints of marked swelling in the floor of the mouth with dysphagia. The patient reveals that when the pain began, she only experienced it when there was contact between the teeth and there was no swelling at that point.

Upon examination, your clinician notes that the patient had a significant swelling of the floor of the mouth involving the submental space. The patient’s front anterior teeth showed discoloration and the patient revealed that she had a history of trauma several years back after which the front teeth was slowly getting discolored. The patient had no signs of symptoms of any kind of respiratory distress.

Based on signs and symptoms, history and imaging studies, your surgeon makes a diagnosis of periapical abscess involving the submental area. He performs an incision and drainage procedure by accessing the submental area through an extraoral route.

What to report: Since your clinician performed an extraoral incision and drainage of the submental area, you report 41016. You report the diagnosis with the ICD-9 code, 522.5 (Periapical abscess without sinus). You report this diagnosis with K04.7 (Periapical abscess without sinus) if you are using ICD-10 codes.

Know CCI Rules For I&D Procedures

There are no Correct Coding Initiative (CCI) edits when your clinician makes two incisions for draining an abscess, cyst or hematoma from two different spaces, using the extraoral route. However, in the unlikely scenario that your clinician uses an intraoral and extraoral approach for draining a cyst, abscess or hematoma from the sublingual or submental spaces, you will have to watch CCI for edits. You do not have these edits for such an approach used for the submandibular space.

Consider this scenario: Your clinician may use both an intraoral route and extraoral route for I&D procedures when there is more than one lesion (present bilaterally) that needs drainage and the anatomical location of these individual lesions necessitate such an approach. “Anatomically, the spaces run adjacent to or in close proximity to each other and are only separated by facial and tissue or muscle planes, suggests Barry Shipman, DMD, clinical professor, University of Florida School of Dentistry, Hialeah Dental Center. “As long as there is a clear differentiation of anatomical landmarks, then involvement in separate planes could be appropriate.”

According to the edits, you will face bundling if you are trying to report 41015 with intraoral sublingual I&D codes, 41005 (Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, superficial) or 41006 (Intraoral…sublingual, deep, supramylohyoid). You will again face edits when trying to report 41016 with 41007 (Intraoral…submental space).

Modifier indicator: 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). Since both the extraoral approach codes are the column 2 codes in the code bundling, you will have to append the modifier to these codes to override the edit.

Watch For Instances to Report E/M Codes Additionally

Any pre-operative evaluation of the hematoma, cyst or abscess that your oral surgeon performs prior to the I&D procedure will be included in the work involved in the I&D code that you choose to report for the procedure. You will not report an additional E/M code for this work involved.

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 extraoral 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.

Caveat: You can 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.

Example: Your oral surgeon decides to perform an I&D procedure for an established patient whom he diagnoses with cellulitis of the floor of the mouth caused due to an infected third molar.

The patient’s past history reveals that he has undergone a coronary bypass and is currently on anticoagulant therapy. As this might cause some issues such as uncontrolled bleeding, your clinician evaluates the patient further and checks prothrombin time that reveals a PTT of 2.4.

Your surgeon then proceeds to perform the I&D through an extraoral approach to the submandibular space.

What to report: You report the I&D procedure with 41017. Since your surgeon had to probe further to evaluate the patient as he is on anticoagulant therapy, you report the evaluation of the patient with an appropriate E/M code (such as 99212, Office or other outpatient visit for the evaluation and management of an established patient…) with the modifier 25 appended.