Oral Surgery Coding & Reimbursement Alert

Question: Our oral surgeon recently performed drainage of the submandibular space. The op report read that the space was infected due to an abscess. What CPT^® and diagnosis codes should I report for the procedure performed?

Kentucky Subscriber

Answer: For determining what CPT^® code you will need to report the drainage of an abscess affecting the submandibular space, you will need to see through documentation to check what access your surgeon used for the procedure.

If your clinician accessed the submandibular space using an intraoral approach, you will need to report the procedure using 41008 (Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular space). If the approach used by your surgeon was extraoral, you will need to report the procedure using 41017 (Extraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular).

You have not mentioned what caused the abscess that infected the submandibular space. So, you will need to select the appropriate (ICD-10) diagnosis code by looking through documentation to see what your clinician has mentioned as the cause for the infection of the submandibular space.

If the infection occurred as a result of a periapical infection, you will need to report the diagnosis using K04.7 (Periapical abscess without sinus). If the abscess was caused due to any other oral tissues, you can report the diagnosis using K12.2 (Cellulitis and abscess of mouth).

If your clinician diagnosed that the infection of the submandibular space was caused due to an abscess of the salivary gland, you can report the diagnosis as K11.3 (Abscess of salivary gland).

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