tag60
Guru
I feel like I'm going in circles trying to find the appropriate code for a patient who has a lesion / nodule on his gums. Provider documentation as follows:
Pt has a prior history of a mucocele and now presents with a similar lesion on upper left gum, currently small. Occasionally grows very large and pushes his lip out. Denies fevers, chills.
Exam: Left upper mid-lateral gums with nodule approx 0.7 mm.
Dx: Neoplasm of gum (D49.0). Possible mucocele. Will refer to ENT.
From the research I've done on this forum, I understand I can't code as neoplasm of unspecified behavior (the code the provider chose above), or even as benign neoplasm because no study has been performed.
A search under "nodule" on gums (term used in exam) leads to R22.0, localized swelling/mass/lump of head.
A search under "lesion" on gums (term used in HPI) leads to K13.79, which is mucocle, but which provider said was "possible"so I don't know about using that...
but a search under "lesion, oral" also leads to K13.79. And I also see K13.70, unspecified lesions of oral mucosa, as a possibility.
I guess it comes down to what term to search under.
The exam is the objective part, and "nodule" is used there, leading to R22.0 -- but K13.70 seems more precise, and "unspecified" lesion here would refer to not knowing what type it is at this point, correct?
How would you code this?
Thank you in advance!
Pt has a prior history of a mucocele and now presents with a similar lesion on upper left gum, currently small. Occasionally grows very large and pushes his lip out. Denies fevers, chills.
Exam: Left upper mid-lateral gums with nodule approx 0.7 mm.
Dx: Neoplasm of gum (D49.0). Possible mucocele. Will refer to ENT.
From the research I've done on this forum, I understand I can't code as neoplasm of unspecified behavior (the code the provider chose above), or even as benign neoplasm because no study has been performed.
A search under "nodule" on gums (term used in exam) leads to R22.0, localized swelling/mass/lump of head.
A search under "lesion" on gums (term used in HPI) leads to K13.79, which is mucocle, but which provider said was "possible"so I don't know about using that...
but a search under "lesion, oral" also leads to K13.79. And I also see K13.70, unspecified lesions of oral mucosa, as a possibility.
I guess it comes down to what term to search under.
The exam is the objective part, and "nodule" is used there, leading to R22.0 -- but K13.70 seems more precise, and "unspecified" lesion here would refer to not knowing what type it is at this point, correct?
How would you code this?
Thank you in advance!