Oral Surgery Coding & Reimbursement Alert

Click on the same code for mucous retention cyst diagnosis too.

If your oral surgeon’s diagnosis is mucocele or oral ranula, your reporting will not change much when you begin adapting to using ICD-10 codes post Oct. 1, 2015. You will only have to switch to using a simple one-to-one common crossover code for both these conditions in ICD-10.

ICD-9: When your oral surgeon diagnoses a patient with mucocele of the salivary glands, you report the condition with the ICD-9 code, 527.6 (Mucocele of salivary gland). In addition to reporting the code for mucocele of the salivary glands, you can also use this ICD-9 code when your surgeon diagnoses a patient with extravasation cyst of the salivary gland; mucous retention cyst of the salivary gland. You can also use 527.6 for a diagnosis of oral or plunging ranula.

ICD-10: When you begin using ICD-10 codes, you will have a simple one-to-one crosswalk to choose for a diagnosis of mucocele of salivary gland. You report this diagnosis with the ICD-10 code, K11.6 (Mucocele of salivary gland). As in ICD-9, you will use the same diagnosis code for other diagnoses such as mucous extravasation cyst of salivary gland; mucous retention cyst of salivary gland and ranula.

Focus on These Basics Briefly

Documentation spotlight: Some of the common findings that you will normally come across when your surgeon diagnoses a patient with mucocele of the salivary gland will include asymptomatic swelling in the area of the labial mucosa, the ventral aspect of the tongue, floor of the mouth, buccal mucosa, palatal surface or the retromolar area. While mostly these patients might not complain of any pain, patients with superficial mucoceles might complain that the condition is painful. In case of an oral ranula, the swelling will be found in the area below the tongue and is often painful. Also, an oral ranula will cause difficulties in speech, mastication and swallowing. Sometimes, the patient might have respiratory difficulties also.

Upon examination, your surgeon will note the presence of a swelling with an intact epithelium that is usually mobile and non-tender. Your clinician will usually document the presence of a small swelling but sometimes larger swellings to a size of about 3-4 cm can also be found. Your surgeon might note that the swelling has an intact mucosal lining although sometimes he might mention that it appears to have a rough surface. Your surgeon might also note the presence of a draining sinus on the lesion from which mucinous content oozes out.

In case of a ranula, your clinician’s findings on examination will be similar to the findings mentioned above. However, the lesion will typically be larger in size and be present in the floor of the mouth below the tongue.

Tests: There are no specific tests that your clinician will order to confirm the diagnosis of mucocele or oral ranula. Your clinician also will not order for any imaging studies if the lesion is a mucocele. However, he might order for occlusal view or panoramic view x-rays along with other imaging studies such as CT scan, MRI or an ultrasonography to confirm and check the extent of an oral ranula.

For oral mucoceles, your clinician might want to perform an excisional biopsy and send it to the lab for a confirmatory histological study. For oral ranulas, your clinician might perform a fine needle aspiration biopsy to confirm the diagnosis prior to performing a surgical excision or marsupialization.

Based on history, signs and symptoms, results from tests and diagnostic imaging studies, your clinician will arrive at a diagnosis of mucocele or ranula of the salivary glands.