Oral Surgery Coding & Reimbursement Alert

Reader Question:

Choose Maxillary I&D Codes Based on Origin of Abscess

Published on Wed Jul 20, 2016

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Question: Our oral surgeon recently performed incision and drainage of an abscess of the maxilla on the left side using an intraoral approach. When I am looking at incision and drainage codes, I can only see codes for drainage of an abscess from the floor of the mouth and there are no codes to report for I & D of the maxilla. Please let me know what codes I have to report for the procedure that our surgeon performed?

Michigan Subscriber

Answer: In the above scenario, you haven’t mentioned about the anatomical structure from which the abscess has been caused. If the abscess has been caused due to an infected tooth, you will have to report the condition as an abscess of the dentoalveolar structures. In such a case, you will have to report it with the CPT^® code 41800 (Drainage of abscess, cyst, hematoma from dentoalveolar structures).

On the other hand, if the abscess has not originated from a tooth or any other supporting structures of the tooth, you can use drainage of abscess from the vestibule of the mouth codes. In such a case, you have two reporting options to report the drainage of the abscess depending on the complexity of the procedure. The two code choices that you have for reporting drainage of an abscess from the vestibule of the mouth include:

40800 (Drainage of abscess, cyst, hematoma, vestibule of mouth; simple)
40801 (…complicated).

So, you will choose 40800 if your clinician performs an incision to drain the abscess and places simple sutures at the end of the procedure or does not perform any repair. You can choose 40801 if your clinician performs the incision and drainage that is more complicated.

You can choose the complex drainage code when your surgeon has difficulty in reaching the abscess as it is located deeper or when the location of the abscess is more close to nerves and important blood vessels and your clinician will need to exercise more care in reaching the abscess while taking care not to cause any damage. You can also choose 40801 when your clinician needs to perform extensive instrumentation to break down pockets or loculations while draining the abscess.