Oral Surgery Coding & Reimbursement Alert

Hint: Look for other ICD-10 codes for abscess of the tongue.

When your surgeon diagnoses cellulitis of the floor of the mouth, you report it in the same way as you did in ICD-9. Along with a simple crossover code for the condition, you also have a similar list of exclusions as in ICD-9.

ICD-9: When your oral surgeon arrives at a diagnosis of cellulitis involving the floor of the mouth, you report the diagnosis with the ICD-9 code, 528.3 (Cellulitis and abscess of oral soft tissues). You report the same diagnosis code when your surgeon diagnoses the patient with cellulitis of mouth (floor); Ludwig’s angina or oral fistula.

Caveat: You cannot report 528.3 if your clinician diagnoses the patient with abscess of tongue or cellulitis or abscess of lip. You report this with 529.0 (Glossitis) and 528.5 (Diseases of lips) respectively. Similarly, you cannot report 528.3 if your surgeon diagnoses the condition to be a dental fistula or a fistula of the lip. You report this with 522.7 (Periapical abscess with sinus) and 528.5 respectively. If your clinician’s diagnosis is gingivitis, you report it with the ICD-9 code range 523.00-523.11 instead of 528.3.

ICD-10: When you begin using ICD-10 codes after Oct.1, 2015, a diagnosis of cellulitis that you report with 528.3 in ICD-9 will crosswalk to K12.2 (Cellulitis and abscess of mouth). As in ICD-9, you use the same diagnosis code if your surgeon diagnoses the condition as either cellulitis of mouth (floor) or submandibular abscess.

Reminder: Similar to the exclusion list in ICD-9, you cannot report K12.2 if your oral surgeon diagnoses the patient with abscess of the tongue or an abscess of the salivary gland. You will report this with the ICD-10 codes, K14.0 (Glossitis) and K11.3 (Abscess of salivary gland) respectively. You also cannot report other abscess such as periapical abscess, periodontal abscess or a peritonsillar abscess with K12.2. You report these with K04.6 (Periapical abscess with sinus)-K04.7 (…without sinus), K05.21 (Aggressive periodontitis, localized) and J36 (Peritonsillar abscess).

Focus on These Basics Briefly

Documentation spotlight: Some of the symptoms that you will normally come across when your clinician identifies the diagnosis as cellulitis of the floor of the mouth will include bilateral swelling of the floor of the mouth, pain, respiratory difficulties, swallowing difficulty, elevation of the tongue, fever, malaise and trismus.

When your surgeon suspects a diagnosis of cellulitis of the floor of the mouth, he will record a thorough history that includes a history of any pain related to the tooth or teeth in the past, recent dental procedures or of any trauma to the jaw area. Your clinician will also query the patient whether or not he had such symptoms in the past.

Upon examination, your surgeon will note the presence of swelling along with some degree of elevation of the tongue and the floor of the mouth. He will also note the presence of dental problems that might be the cause for the cellulitis. He will also examine the patient for signs of respiratory distress and if this is present, it has to be handled as a medical emergency. He will also check for the presence of difficulties in opening and closing of the mouth as well as check for lymph node involvement.

Tests: Your clinician might ask for certain lab tests if he suspects cellulitis of the floor of the mouth. He will withdraw blood for CBC, electrolyte count and other blood tests. He might also order for a blood culture to help identify the causative organism for effective antibiotic therapy.

Some of the diagnostic tests that your surgeon might also order when he suspects a diagnosis of cellulitis will include x-rays), ultrasound or a CT scan.

Based on history, signs and symptoms, results from tests and diagnostic imaging studies, your clinician will arrive at a diagnosis of cellulitis of the floor of the mouth.

Example: Your oral surgeon examines a 19-year-old female patient admitted in the hospital with complaints of severe swelling in the area of the floor of the mouth that was increasing from the past three to four days. She also complained of severe pain while she tried to swallow and had reduced ability to open her mouth.

She told that she had no such experience in the past and this was the first time that she had developed the pain and swelling. Upon examination, your clinician notes the presence of an impacted and carious third molar and marked swelling of the floor of the mouth. The patient did not seem to be experiencing any kind of respiratory distress.

Your clinician also notes elevated temperature and tachycardia while her respiratory rate was about normal. Lab results of blood tests showed elevation of white blood count while blood culture was not conclusive. X-rays taken of the area showed soft tissue prominence while ultrasound showed signs of abscess formation.

Based on signs and symptoms and test results, your oral surgeon diagnosed the patient with cellulitis of the floor of the mouth and the patient was initiated on antibiotic therapy and placed on observation.

What to report: You report the evaluation of the patient with an inpatient E/M code such as 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components…moderate severity. Typically, 50 minutes are spent at the bedside and on the patient’s hospital floor or unit). You report the diagnosis with K12.2 if you are using ICD-10 codes or report 528.3 if you’re using ICD-9 codes.