Oral Surgery Coding & Reimbursement Alert

Hint: Don’t get confused with diagnosis with similar terms.

When your clinician arrives at a diagnosis of oral hairy leukoplakia, look for the specific code to report this condition. You should not confuse this diagnosis with oral leukoplakia or leukokeratosis nicotina palati while being aware of what other additional codes you will have to report when your oral surgeon diagnoses hairy leukoplakia.

When your surgeon identifies the diagnosis as oral hairy leukoplakia, you should remember that there is a specific ICD-10 code to report the condition. You should report this diagnosis with the ICD-10 code, K13.3 (Hairy leukoplakia). The additional notes for this code mention that you use the same ICD-10 code when your clinician identifies the patient’s condition as “epithelial disturbances of tongue.”

When reporting any conditions that are reported under the parent code K13.-, you are also supposed to report additional codes that will identify alcohol abuse and dependence (F10.-); exposure to environmental tobacco smoke (Z77.22); history of tobacco use (Z87.891); occupational exposure to environmental tobacco smoke (Z57.31); tobacco dependence (F17.-) or tobacco use (Z72.0). So if your surgeon identifies a history of tobacco use or dependence or alcohol use or dependence, you will need to report it with additional codes as mentioned.

Caveat: You should not use K13.3 as the diagnosis code that you will report if your clinician identifies the patient with “leukoplakia” and not “hairy leukoplakia.” You should report a diagnosis of leukoplakia of the oral cavity with K13.21 (Leukoplakia of oral mucosa, including tongue). In addition, you cannot use K13.3 for a diagnosis of leukokeratosis nicotina palati or smoker’s palate. You report this condition with the ICD-10 code, K13.24 (Leukokeratosis nicotina palati).

Focus on These Basics Briefly

Documentation spotlight: Some of the common findings that your clinician will record when he arrives at a diagnosis of hairy leukoplakia will include the presence of 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. Some patients do complain of pain and changes to taste sensations. Your clinician might note that these lesions do resolve spontaneously, but newer lesions keep occurring at periodic intervals.

These patients will usually have a history of being HIV positive or being immunocompromised due to some other systematic conditions although the condition is also known to occur in patients who aren’t HIV positive or are not immunocompromised.

Upon examination, your clinician might note the presence of white plaque like lesion(s) mainly on the lateral borders of the tongue although your clinician might observe it in other locations such as the ventral or the dorsal surface of tongue and even in the buccal mucosa. Sometimes, your clinician might note the presence of the lesions in the gingival too. Your surgeon might note that the lesion appears hairy with folds or projections although sometimes the lesions might appear to be smooth and flat. He might note that there is no erythema or edema in the tissue adjacent to the lesion.

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.

Tests: 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.

Based on history, signs and symptoms, results from tests and histological tests, your clinician will arrive at a diagnosis of oral hairy leukoplakia.

Example: Your surgeon reviews a 35-year-old female patient with complaints of white patches on the tongue that have been occurring periodically for many months now. She complains that she has been noticing these patches occurring and resolving spontaneously and she had no discomfort from them although they would appear to be quite unsightly. 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 patient is under medication as she had a kidney transplant a few years back. She has no history of alcohol use but used to smoke two cigarette packs a day prior to undergoing the kidney transplant.

Upon examination, your clinician notes the presence of two lesions on the lateral border of the tongue. The lesions have a folded appearance with one of the lesions bearing a slightly ulcerated surface while your clinician notes that the surrounding tissue appears to be normal. Based on clinical appearance, your clinician suspects a diagnosis of oral hairy leukoplakia. Since one of the lesions had an ulcerated appearance, your surgeon opts to perform a biopsy and sends the sample for histological studies.

Based on history, signs and symptoms, observations of clinical examination and histological studies, your clinician arrives at the diagnosis of oral hairy leukoplakia.

What to report: You report the biopsy that your clinician performed with 41105 (Biopsy of tongue; posterior one-third). You report the diagnosis of hairy leukoplakia with K13.3. Since the patient has had a history of tobacco use in the past, you will need to report this with an additional code using Z87.891.

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