Oral Surgery Coding & Reimbursement Alert

Question: Our maxillofacial surgeon recently removed a mucocele from the buccal mucosa. When I am looking at ICD-9, I can see that I can choose 527.6 which can also be used for a diagnosis of ranula. Since there is a CPT® code, 42408, for the removal of a ranula, can I use the same code for the removal of a mucocele?

Michigan Subscriber

Answer: You are right that both mucocele and oral ranula are reported with the same ICD-9 code (527.6, Mucocele of salivary gland) and ICD-10 code (K11.6, Mucocele of salivary gland). Even though you use the same diagnosis codes for both the conditions, you still cannot report the removal of a mucocele using 42408 (Excision of sublingual salivary cyst [ranula]) as this is a specific CPT® code for the removal of an oral ranula.

You will instead have to look at excision codes for lesions present in the mucosa or the vestibule of the mouth as mucocele is more commonly located in these sites. For choosing the right code for the removal of a mucocele, you will have to look at the extent of dissection and the kind of repair that your surgeon had to perform during closure of the site.

Based on this, you have four codes to choose from for the removal of a mucocele:

• 40810 (Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair)
• 40812 (…with simple repair)
• 40814 (…with complex repair)
• 40816 (…complex, with excision of underlying muscle).

However, as a mucocele will generally be a more superficial lesion, your surgeon will perform either a simple repair or will excise the lesion without repair. So, in most cases, you will only have to report either 40810 or 40812 for the excision procedure of a mucocele.

Alternative: If instead of excision, your clinician removed the lesion using a laser or cryotherapy, you can choose to report 40820 (Destruction of lesion or scar of vestibule of mouth by physical methods [e.g., laser, thermal, cryo, chemical]) instead of the above mentioned removal codes.