Otolaryngology Coding Alert

Question: Our surgeon recently performed drainage of an abscess in the submandibular space (the abscess had led to infection). What CPT^® and diagnosis codes should I report for the procedure?

Kentucky Subscriber

Answer: Before you can assign a drainage code, you need to look through the documentation to check what access your surgeon used for the procedure.

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

We cannot recommend a diagnosis code because you didn’t mention what caused the abscess that infected the submandibular space. Look through the documentation to see what your clinician noted as the cause of infection and choose the appropriate ICD-10 code based on that information.

For example, if the infection occurred as a result of a periapical infection, you should report diagnosis K04.7 (Periapical abscess without sinus). If the abscess was caused due to any other oral tissues, you can submit K12.2 (Cellulitis and abscess of mouth). If an abscess of the salivary gland caused the infection, you can report the diagnosis as K11.3 (Abscess of salivary gland).