Oral Surgery Coding & Reimbursement Alert

Hint: Don’t forget to report additional codes for drug related mucositis.

When reporting a diagnosis of oral ulcerative mucositis, you’ll have to report the condition based on the etiology as you did in ICD-9. Your reporting of the condition in ICD-10 is very similar to the way you did in ICD-9 although you now have an additional code for mucositis caused due to radiation (external causative agents).

ICD-9:  When your clinician arrives at a diagnosis of oral ulcerative mucositis, you begin with the ICD-9 code, 528.0 (Stomatitis). Then, depending on the cause that your oral surgeon attributes for the mucositis, you have the following 5^th digit expansions to 528.0 to choose from:

• 528.00 (Stomatitis and mucositis, unspecified)

• 528.01 (Mucositis [ulcerative] due to antineoplastic therapy)

• 528.02 (Mucositis [ulcerative] due to other drugs)

• 528.09 (Other stomatitis and mucositis [ulcerative])

If your clinician has not identified the cause for the oral ulcerative mucositis, you will have to resort to using 528.00 to report the diagnosis. If the mucositis has been caused due to antineoplastic therapy, you will have to report 528.01. You will have to report an additional E code to identify that this condition has been caused as a result of an adverse effect of the antineoplastic therapy.

If the therapy was through antineoplastic drugs or immunosuppressive drugs, you will have to use E930.7 (Antineoplastic antibiotics causing adverse effects in therapeutic use) or E933.1 (Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use) as an additional code. If the oral mucositis has been caused as a side effect of radiation, you will have to use E879.2 (Radiological procedure and radiotherapy as the cause of abnormal reaction of patient or of later complication without misadventure at time of procedure) along with 528.01.

If the mucositis was caused as an adverse effect of a drug other than antineoplastic or immunosuppressive drugs, you will have to report 528.02. Again, as with 528.01, you will have to report an additional E code to identify the drug that has caused the adverse effect. You will have to use 528.09 if the mucositis has a viral etiology.

ICD-10: When you begin using ICD-10 codes, you have to switch over to using K12.3 (Oral mucositis [ulcerative]) for a diagnosis of oral ulcerative mucositis. As in ICD-9, you have a further expansion to K12.3 depending on the etiology for the mucositis. You will have to choose from the following expansions to K12.3 on the basis of the cause that your clinician identifies:

• K12.30 (Oral mucositis [ulcerative], unspecified)

• K12.31 (Oral mucositis [ulcerative] due to antineoplastic therapy)

• K12.32 (Oral mucositis [ulcerative] due to other drugs)

• K12.33 (Oral mucositis [ulcerative] due to radiation)

• K12.39 (Other oral mucositis [ulcerative])

As with ICD-9, you use K12.30 when your clinician does not identify the cause for the oral ulcerative mucositis. If the patient has undergone chemotherapy and the oral mucositis is an adverse effect of it, you report K12.31. You will have to report an additional code such as T45.1X5 (Adverse effect of antineoplastic and immunosuppressive drugs) in addition to K12.31 to identify that the mucositis is an adverse effect of the chemotherapy.

On the other hand, if the patient has undergone radiation to treat the cancer, you will have to report K12.31 and report Y84.2 (Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure) as an additional code.

If the mucositis was caused as an adverse effect of a drug other than antineoplastic or immunosuppressive drugs, you will have to report K12.32. You will have to report an additional code to identify the drug (T36-T50 with fifth or sixth character 5) that has caused the adverse effect. If the mucositis has a viral etiology, you will have to report it with the ICD-10 code, K12.39.

In ICD-10, you have an additional code, K12.33 to report oral mucositis that has been cause as an effect of exposure to radiation (such as ionizing radiation, occupational exposure to radiation, sunlight, etc). When reporting this ICD-10 code, you will have to report an additional code (W88-W90, X39.0-) to identify the cause that your clinician attributes to the occurrence of the mucositis.

Brush up on These Basics Briefly

Documentation spotlight: A few of the common findings that your clinician will record when he arrives at a diagnosis of oral ulcerative mucositis will include pain in the oral cavity, redness of the mucosal areas, dryness of the mouth, problems with mouth opening, hardship with cleaning the teeth and surrounding structures and difficulty with speech, eating food and consuming liquids. The patient might also complain of reduced appetite and alteration to taste sensations. The patient will have a history of radiation or chemotherapy or might be taking some other drugs for a significant period of time.

Upon examination, your clinician might note the presence of erythema and presence of ulceration on the buccal mucosa, labial mucosa, tongue, soft palate, floor of the mouth and the oropharynx. Your clinician might note that there is the presence of spontaneous bleeding from the erythematous mucosal areas. Your clinician might also note the presence of hairy tongue along with a similar dark appearance in the areas of the gingival and the hard palate.

Tests: Your clinician will arrive at the diagnosis of oral ulcerative mucositis based on history, signs and symptoms and from physical examination of the patient. Usually, no special tests will be necessary to arrive or confirm a diagnosis of ulcerative mucositis.

However, your clinician might resort to ordering for a culture in some cases when the ulcers are not spontaneously healing after a period of a week to ten days to rule out other infections being present. In certain patients, if your clinician suspects the presence of infections, a biopsy of the area might also be done.

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