Coding for Oral and Maxillofacial Pathology

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Coding for Oral and Maxillofacial The lesion has a clear-colored appearance and is soft and
Pathology non-painful to palpation. The lesion feels fluid-filled and
measures 5mm by 5mm by 3mm in greatest dimension.
I. INTRODUCTION The lesion is located on the vestibular mucosa of the right
lower lip, midway from the right corner of the mouth to
Detailed discussion of evaluation and management (E/M) the midline of the lower lip.
codes is not within the scope of this paper. However, this
paper highlights some of the coding axioms with regard to The lesion interferes with his speech and ability to chew
the "global surgical package" concept. food. The patient is concerned about the etiology and
pathology of this lesion.
CPT codes should be used for coding procedures related
to oral and maxillofacial pathology whenever possible, but Diagnosis: Mucous Retention Cyst 527.6
ADA or CDT (Current Dental Terminology) coding may
overlap with CPT and may be preferred by some carriers. Surgical Treatment Options:
For this reason, these codes are included at the end of the
paper. 1. Excision of lesion of mucosa and submucosa, vestibule
of mouth; 40810, 40812, 40814 or 40816 depending on
Common ICD-9-CM Codes for Oral and the extent of the surgery and repair
Maxillofacial Pathology:
2. Biopsy, vestibule of mouth
Common diagnostic codes for oral lesions include: 40808

526- Diseases of Jaw 3. Marsupialization of the Lesion:
40801 incision of cyst, complicated
527- Diseases of the salivary gland
II. ICD-9-CM DIAGNOSIS CODES
528- Diseases of the oral soft tissue, excluding lesions
specific for gingiva and tongue The diagnosis codes for neoplasms can be found in the
neoplasm table in the ICD-9-CM manual. The manual
529- Diseases and other conditions of the tongue includes codes for primary and secondary malignancies,
carcinoma-in-situ, benign, uncertain behavior and unspec-
These codes are intended to point out rather common ified neoplasms for each site. These codes can be updated
lesions. annually and as such, each surgeon must utilize updated
and current coding manuals.
Example of a common soft tissue lesion of the oral and
maxillofacial region: III. CPT CODING FOR ORAL and
MAXILLOFACIAL PATHOLOGY
The patient presents for evaluation and treatment with the
chief complaint of lesion of the lower lip. His physician The differences between Destruction, Excision, Repair and
refers the patient for this evaluation and treatment. The Introduction are as follows:
patient is a healthy 25-year-old male with an unremarkable
past medical and social history. Destruction involves the use of a laser or electrocautery to
burn the lesion, cryotherapy to freeze the lesion, or chem-
The patient states that the lesion occurred about "3 weeks icals to destroy the lesion. The surgeon destroys benign,
ago and goes up and then down from time to time, but premalignant and malignant lesions.
never totally goes away." The patient states that this is the
first time that he has experienced this type of lesion. He
does not recall trauma or other injury to this area.

PAGE 1 Coding for Oral and Maxillofacial Pathology

Excision is when the physician makes an incision through Coding Paper
the skin, undermining the subcutaneous tissue beneath the
lesion to remove the lesion. HEAD (Skull, Facial Bones and
Introduction is when the physician uses a syringe to inject Temporomandibular Joint)
a pharmacological agent underneath or into skin or oral This includes incision, excision, introduction or removal,
lesions (usually seven or less). The lesion may be any skin repair, revision, and/or reconstruction, fracture and/or
or oral lesion including post surgical scar bands. The phy- dislocation, manipulation and other related procedures;
sician may inject steroids or anesthetics into these lesions. referencing the following CPT codes:
Repair referencing CPT codes 15780 thru 15879, includes
various types of dermabrasions, chemical peels, certain 21010
types of face-lifts and some liposuction to certain areas of 21015 thru 21073
the body. 21110
21181 thru 21196
INTEGUMENTARY SYSTEM 21240 thru 21243
This would include incision, drainage, biopsy, excision, 21299
destruction, introduction and repair referencing the follow- 21497
ing CPT codes: 21499

10060 thru 10061 NECK (Soft Tissues) and Thorax
10120 thru 10180 This includes incision, excision, and endoscopy/arthros-
11000 thru 11001 copy; referencing the following CPT codes:
11010 thru 11047
11055 thru 11057 21501 and 21510
11100 thru 11101 21550 thru 21557
11200 and 11201
11305 thru 11313 ENDOSCOPY/ARTHROSCOPY
11420 thru 11446 29800 thru 29804
11620 thru 11646
11900 thru 11901 RESPIRATORY SYSTEM (Nose and Accessory
17000 thru 17250 Sinuses)
17270 thru 17286 This includes incision, excision, introduction, destruction,
17311 thru 17315 other related procedures, accessory sinuses and endoscopy
referencing the following CPT codes:
AUDITORY SYSTEM (External Ear)
This includes incision, excision and temporal bone; 30000 and 30020
referencing the following CPT codes: 30100 thru 30160
30200
69000, 69005, 69020 30801 and 30802
69100 thru 69155 30901 thru 30920
30999
MUSCULOSKELETAL SYSTEM (General) 31000
This includes incision, excision introduction or removal; 31020 thru 31087
referencing the following CPT codes:

20005
20200 thru 20245
20500, 20501, 20605, 20615, 20999

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31200 thru 31230 Coding Paper
31231 thru 31294
31299 TONGUE AND FLOOR OF MOUTH
This includes incision and excision referencing the follow-
PHARYNX, ADENOIDS AND TONSILS ing CPT codes:
This includes incision, excision and destruction; referenc-
ing the following CPT codes: 41000 thru 41009
41015 thru 41018
42700 thru 42725 41100 thru 41155
42800 thru 42815
IV. CDT CODING FOR ORAL and
SALIVARY GLAND AND DUCTS MAXILLOFACIAL PATHOLOGY
This includes incision, excision, repair and other proce- D4210 Gingivectomy or gingivoplasty - four or more
dures referencing the following CPT codes:
contiguous teeth or tooth bounded spaces per
42300 thru 42699 quadrant

DENTOALVEOLAR STRUCTURES D4211 Gingivectomy or gingivoplasty - one to three
This includes incision, excision and destruction referenc- contiguous teeth or tooth bounded spaces per
ing the following CPT codes: quadrant

41800 D4230 Anatomical crown exposure - four or more con-
41820 thru 41850 tiguous teeth per quadrant
41870 thru 41874
41899 D4241 Gingival flap procedure, including root planing
- one to three contiguous teeth or tooth bounded
PALATE AND UVULA spaces per quadrant
This includes incision, excision and destruction referenc-
ing the following CPT codes: D4245 Apically positioned flap

42000 thru 42160 D4249 Clinical crown lengthening-hard tissue

HEMIC AND LYMPHATIC SYSTEMS (Lymph D4267 Guided tissue regeneration - nonresorbable
Nodes and Lymphatic Channels) barrier, per site, (includes membrane removal)
This includes incision, excision and radical lymphadenec-
tomy referencing the following CPT codes: D4268 Surgical revision procedure, per tooth

38300 thru 38305 D4270 Pedicle soft tissue graft procedure
38380
38500 thru 38555 D7285 Biopsy of oral tissue -- hard (bone, tooth)
38700 thru 38724
D7286 Biopsy of oral tissue - soft
DIGESTIVE SYSTEM (Lips and Vestibule of
Mouth) D7310 Alveoloplasty in conjunction with extractions -
This includes excision, incision and destruction referenc- four or more teeth or tooth spaces, per quadrant
ing the following CPT codes:
D7311 Alveoloplasty in conjunction with extractions -
40490 thru 40530 one to three teeth or tooth spaces, per quadrant
40800 thru 40801
40808 thru 40820 D7320 Alveoloplasty not in conjunction with extractions -
four or more teeth or tooth spaces, per quadrant
PAGE 3 Coding for Oral and Maxillofacial Pathology
D7321 Alveoloplasty not in conjunction with extractions -
one to three teeth or tooth spaces, per quadrant

D7410 Excision of benign lesion up to 1.25 cm Coding Paper

D7411 Excision of benign lesion greater than 1.25 cm D7830 Manipulation under anesthesia
D7840 Condylectomy
D7412 Excision of benign lesion, complicated D7850 Surgical discectomy; with/without implant
D7852 Disc repair
D7413 Excision of malignant lesion up to 1.25 cm D7860 Arthrotomy
D7870 Arthrocentesis
D7414 Excision of malignant lesion greater than 1.25 D7871 Non-arthroscopic lysis and lavage
cm D7872 Arthroscopy-diagnosis, with or without biopsy
D7873 Arthroscopy-surgical: lavage and lysis of adhe-
D7415 Excision of malignant lesion, complicated
sions
D7440 Excision of malignant tumor-lesion diameter up D7874 Arthroscopy-surgical: disc repositioning and
to 1.25 cm
stabilization
D7441 Excision of malignant tumor-lesion diameter D7875 Arthroscopy-surgical: synovectomy
greater than 1.25 cm D7876 Arthroscopy-surgical: discectomy
D7877 Arthroscopy-surgical: debridement
D7450 Removal of benign odontogenic cyst or tumor-le- D7920 Skin graft (identify defect covered, location, and
sion diameter up t0 1.25 cm
type of graft)
D7451 Removal of benign odontogenic cyst or tumor-le- D7921 Collection and application of autologous blood
sion diameter greater than 1.25 cm
concentrate product
D7460 Removal of benign nonodontogenic cyst or tu- D7955 Repair of maxillofacial soft and/or hard tissue
mor-lesion diameter up to 1.25 cm
defect
D7461 Removal of benign nonodontogenic cyst or tu- D7960 Frenulectomy (frenectomy or frenotomy)-sepa-
mor-lesion diameter greater than 1.25 cm
rate procedure
D7465 Destruction of lesion(s) by physical or chemical D7970 Excision of hyperplastic tissue-per arch
methods, by report D7971 Excision of pericoronal gingiva
D7980 Sialolithotomy
D7472 Removal of torus palatinus D7981 Excision of salivary gland, by report
D7982 Sialodochoplasty
D7473 Removal of torus mandibularis D7983 Closure of salivary fistula
D7991 Coronoidectomy
D7490 Radical resection of maxilla or mandible D7999 Unspecified oral surgery procedure, by report

D7510 Incision and drainage of abscess-intraoral soft
tissue

D7511 Incision and drainage of abscess - intraoral soft
tissue - complicated (includes drainage of multi-
ple fascial spaces)

D7520 Incision and drainage of abscess-extraoral soft
tissue

D7521 Incision and drainage of abscess - extraoral soft
tissue - complicated (includes drainage of multi-
ple fascial spaces)

D7530 Removal of foreign body from mucosa, skin, or
subcutaneous alveolar tissue

D7560 Maxillary sinusotomy for removal of tooth frag-
ment or foreign body

PAGE 4 Coding for Oral and Maxillofacial Pathology

Coding Paper

Note: This paper should not be used as the sole reference in coding. This is one in a series of AAOMS papers designed to provide
Both diagnosis and treatment codes change frequently, and insurance information on coding claims for oral and maxillofacial surgery
carriers may differ in their interpretations of the codes. (OMS). This paper discusses coding for coding for oral and
maxillofacial pathology. This paper is to aid the oral and maxillo-
Coding and billing decisions are personal choices to be made by facial surgeon with proper diagnosis (ICD-9-CM) and treatment
individual oral and maxillofacial surgeons exercising their own profes- (CPT/CDT) coding for coding for oral and maxillofacial pathology.
sional judgment in each situation. The information provided to you in When indicated, you will be referred to the appropriate area of
this paper is intended for educational purposes only. In no event shall the coding books where the principles of coding illustrated in this
AAOMS be liable for any decision made or action taken or not taken paper may be applied.
by you or anyone else in reliance on the information contained in this
article. For practice, financial, accounting, legal or other professional Proper coding provides a uniform language to describe medical,
advice, you need to consult your own professional advisers. surgical, and dental services. Diagnostic and procedure codes
are continually updated or revised. The AAOMS Committee on
Health Care and Advocacy has developed these coding guide-
lines in order to assist the membership to use the coding systems
effectively and efficiently.

© 2013 American Association of Oral and Maxillofacial Surgeons.
No portion of this publication may be used or reproduced without
the express written consent of the American Association of Oral
and Maxillofacial Surgeons.

Revised March 2013

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