Oral Surgery Coding & Reimbursement Alert

Question: Our surgeon recently made the diagnosis of xerostomia. What ICD-10 code should I use to report this diagnosis that our surgeon made?

Michigan Subscriber

Answer: Xerostomia, or dry mouth, is a condition in which the salivary glands don’t produce enough saliva to keep the mouth wet. Dry mouth can cause difficulties in tasting, chewing, swallowing, and speaking, and may cause infections of the mouth.

Under ICD-9, you would report the condition using the code, 527.7 (Disturbance of salivary secretion) for patients diagnosed with dry mouth condition. In ICD-10, you now have two options to report dry mouth in a patient:

• K11.7 – Disturbances of salivary secretion
• R68.2 – Dry mouth, unspecified.

Though you have two options, you will have to report a diagnosis of dry mouth with K11.7. If your clinician reports the dry mouth as a symptom (such as in Sjogren’s syndrome), then you report the dry mouth with R68.2.

Your clinician will arrive at a diagnosis of xerostomia on evidence obtained from the patient’s history, an examination of the oral cavity and/or sialometry, a simple office procedure that measures the flow rate of saliva. Your physician should point to this diagnosis if the patient complains of dry mouth, particularly at night, or of difficulty eating dry foods such as crackers.

Some payers will consider the administration of amifostine medically reasonable and necessary to reduce the incidence of moderate to severe xerostomia in patients undergoing radiation treatment for head and neck cancers. 

Coder tips: In cases where radiation treatment causes xerostomia, you would report the appropriate head and neck cancer codes in addition to K11.7 and L59.9 (Disorder of the skin and subcutaneous tissue related to radiation, unspecified). Check your payer policies to get the final word on which codes they require on the claim for payment.

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