Vol. 15 Issue 6
Coding Mouth and Oral Mucosa Procedures
In the medical record documentation for procedures on the mouth, oral mucosa and dentoalveolar structures, physicians often use varied terminology. One way to improve the code assignment for these procedures is to understand the following points, including terminology.
• Procedures on the lips may be assigned to codes from the integumentary system or the digestive system depending upon the depth of the procedure performed. Coders must check the physician's documentation to determine if the repair of the lip is up to one-half of the vertical height or more than one-half of the vertical height.
• The vestibule of the mouth is that portion of the oral cavity located outside of the dentoalveolar structures (teeth). It includes the submucosal and mucosal tissue of the lips and cheeks.
• The tongue, floor of mouth (that part located below the tongue), dentoalveolar structures, palate and uvula are areas located within and around the mouth. Again, be careful that the documentation supports the code description.
Case Study 1
Preoperative Diagnosis: Severe tongue tie
Postoperative Diagnosis: Severe tongue tie
Procedure Performed: Z-plasty tongue tie release
Procedure Description: The patient was placed in the supine position, and a side mouth gag was placed. The tongue was elevated as much as possible, and a 2-0 black silk suture was placed through the tip of the nose for retraction.
We injected under the nose very, very lightly and in the subcutaneous tissue under the mucosa with 1 percent Xylocaine with Epinephrine. We then separated the tip on the nose from the adhesive portion usually just inside the alveolar ridge of the mandible and stretched the tongue out as much as possible.
Several z-plasties were then outlined and made along the mucosa and the frenulum of the tongue, from the tip of the tongue down to where the submandibular ducts are medially. The mucosal flaps were elevated, transposed and sutured into place with 5-0 chromic catgut interrupted sutures. Bleeding points under the tongue were electrocoagulated with bipolar cautery. Multiple fine interrupted sutures were placed.
The patient was then awakened and taken to the recovery room in satisfactory condition.
Code Assignments and Rationale
ICD-9-CM Diagnosis Code:
750.0 Tongue Tie
CPT Procedure Code
41520 Frenoplasty (surgical revision of frenum, e.g., with Z-plasty)
Rationale: Because the preoperative diagnosis states "severe tongue tie," you will look up the term tongue tie in the index of the ICD-9-CM code book. The index entry directs you to assign code 750.0.
As you read the body of the operative report, you will see that the physician describes a repair of the frenulum by several Z-plasties. First, look up the term tongue in the index of the CPT coding manual, and check the subentries until you locate the term reconstruction. The code beside reconstruction is 41520, which describes "Frenoplasty (surgical revision of frenum, e.g., with Z-plasty). The electrocautery of the bleeding points under the tongue is to control hemostasis and should not be coded separately.
Note that as you scan the subentries you will see the terms Excision Frenum as well as Incision Frenum. Do not be misled to these codes for this particular procedure.
Case Study 2
Preoperative Diagnosis: Carcinoma in situ of the soft palate with associated leukoplakia
Postoperative Diagnosis: Carcinoma in situ of the soft palate with associated leukoplakia
Operative Procedures: CO2 laser ablation of carcinoma in situ and leukoplakia of soft palate extending onto the buccal mucosa and into the retromalar trigone area
Procedure Description: The patient was taken to the operating room and placed
in the supine position. Under general intubational anesthesia, a laser tube was
used. Following this, the head of the bed was rotated, and the Crowe-Davis mouth gag was introduced, expanded, and suspended. Towels were placed on the patient's chest to suspend the end of the Crowe-Davis mouth gag.
Examination of the oral cavity revealed leukoplakia involving the soft palate, left-sided, extending into and over the retro-molar trigone area and onto the buccal mucosa. Transverse dimensions were approximately 7 centimeters. Vertical dimensions from soft palate extending down the palatal glossal fold, about 4 centimeters, possibly 5 centimeters; maybe 4 to 4.5 centimeters.
Using a C02 laser hand-piece, setting of continuous ultra-pulse, 2-3 watts of power, the entire areas of leukoplakia were ablated using a cross-hatch pattern. Following the ablation, wet sponge was used to remove char, there were no islands of mucosa identified in the area of ablation.
Following this, the Crowe-Davis mouth gag was reduced and removed. Anesthesia was reversed, and the patient was taken to the recovery room in good condition. The patient tolerated the procedure well.
Code Assignments and Rationale
ICD-9-CM Diagnosis Codes
230.0 Carcinoma in-situ of the lip, oral cavity and pharynx
528.6 Leukoplakia of oral mucosa, including tongue
CPT Code Assignment
42160 Destruction of lesion, palate or uvula (thermal, cryo or chemical)
Rationale: The physician documented that the patient has carcinoma in situ of the soft palate with associated leukoplakia. He used a CO2 laser to ablate (destroy) the carcinoma in situ and leukoplakia of the soft palate.
To arrive at the ICD-9-CM diagnosis code of 230.0, check the term Carcinoma in the manual index, and you will be directed to "see also Neoplasm, by site." In the neoplasm table, you will look up oral (cavity). In the third column (Ca in situ), you will see the correct code.
For ICD-9-CM diagnosis code 528.6, go to Leukoplakia then to the entry oral soft tissue (including tongue) (Muscosa). This is the correct code.
To assign the CPT code, check in the CPT manual index the term Palate," then check the subentries, and you will see the subterm Lesion. Under the subterm is the entry for Destruction 42160. This code is correct because it describes destruction of lesion, palate or uvula (thermal, cryo or chemical).
Peggy Hapner is the manager of the health information management consulting division at Medical Learning Inc. (MedLearn®), St. Paul, MN.