Oral Surgery Coding & Reimbursement Alert

Hint: Use the same codes for a diagnosis of dentoalveolar abscess.

If your oral surgeon’s diagnosis is periapical abscess, you’ll base your code reporting choice on the presence or absence of a draining sinus. This is similar to the way you would report the condition in ICD-9 coding system.

ICD-9: When your oral surgeon arrives at a diagnosis of periapical abscess, you will have to look at documentation to see if your clinician has mentioned the presence of a draining sinus as this affects reporting the diagnosis. Based on the presence or absence of a sinus, you have two reporting options for a diagnosis of periapical abscess:

• 522.5 (Periapical abscess without sinus)
• 522.7 (Periapical abscess with sinus)

You can also report 522.5 if your oral surgeon’s diagnosis is either dental abscess or a dentoalveolar abscess. If your clinician’s diagnosis is dental fistula or a fistula or the alveolar process, you can report this diagnosis using the ICD-9 code, 522.7.

ICD-10: When you begin using ICD-10 codes, you will again base your reporting of a diagnosis of a periapical abscess on the presence or absence of a draining sinus as you did in ICD-9 coding system. Again, as in ICD-9, you have two code choices for reporting periapical abscess diagnosis:

• K04.6 (Periapical abscess with sinus)
• K04.7 (Periapical abscess without sinus)

You report K04.7 also for a diagnosis of dental abscess without sinus and for a diagnosis of dentoalveolar abscess without a sinus. For a diagnosis of dental abscess with sinus or when your clinician’s diagnosis is dentoalveolar abscess with sinus, you report K04.6.

Check These Basics Briefly

Documentation spotlight: Some of the common findings that your clinician will record when he arrives at a diagnosis of periapical abscess will include pain and swelling in relation to an infected tooth, fever, signs of increased sensitivity to a thermal stimulus and signs of bleeding from the gums.

Upon examination, your surgeon might note tenderness to percussion of the affected tooth, localized swelling and erythema. Your clinician might also note an extrusion of the affected tooth or mobility of the tooth that has been infected. Your surgeon might also note the presence of a draining sinus although this might not be present in every case. Along with this, your clinician might also note the presence of lymph node involvement on the affected side.

Tests: For an uncomplicated periapical abscess, your clinician will not need any lab studies to complete the diagnosis. Only in cases of a complicated abscess such as a cellulitis, your clinician might ask for further lab studies such as CBC, culture or a needle aspirate to help in pharmacological management of the condition.

Your surgeon will order for x-rays such as a periapical x-ray or an OPG to help visualize the infected tooth. For a complicated abscess or cellulitis, your clinician might also order for a CT scan to help confirm the diagnosis and to check the severity of the condition.

Based on history, signs and symptoms, results from tests and diagnostic imaging studies, your clinician will arrive at a diagnosis of periapical abscess.