Oral Surgery Coding & Reimbursement Alert

Question: A family physician referred a patient to our oral surgeon for lesion removal from the floor of the mouth (anterior region). Our surgeon viewed the lesion as potentially more serious and not diagnosable by simple exam. So he performed a thorough exam and biopsy to determine the nature of the lesion. The biopsy returned positive for malignancy, and he scheduled the patient for excision at a later date in the operating room (OR). How should I report this?

Georgia Subscriber

Answer: First, you should report the biopsy with 41108 (Biopsy of floor of mouth). Since the nature of the lesion is not known at this stage, you will have to report the diagnosis as D49.0 (Neoplasm of unspecified behavior of digestive system).

If your surgeon documents a significant, separately identifiable E/M service, you can report an E/M code (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...). You should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to distinguish the E/M service as significantly above that included with the biopsy.

On the later date when your surgeon performs the excision, you will report the procedure with 41116 (Excision, lesion of floor of mouth). After the biopsy, since your surgeon determined the neoplasm to be malignant, you submit a final diagnosis of C04.0 (Malignant neoplasm of anterior floor of mouth).

---