Oral Surgery Coding & Reimbursement Alert

You Be the Coder:

Base Abscess Drainage Code on Location of The Abscess

Published on Tue Jan 12, 2016

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Question: Our surgeon recently performed the following abscess drainage procedure on a 53-year-old male patient with right side facial pain.

Procedure-Dental abscess (right mandibular second molar) incision and drainage. A 2 mm incision was made in the most fluctuant area of the abscess using a #11 blade. Approximately 3 ml blood and pus expressed. The incision was left open without a drain in place. Strict sterile technique was used throughout procedure.

Should I report an abscess drainage of the dentoalveolar structures or an abscess in the floor of the mouth? I am very confused as one of my colleagues is of the opinion that it has to be floor of the mouth and not a dentoalveolar abscess.

Michigan Subscriber

Answer: You will have to report the procedure based on where the abscess was located. If the abscess was located in the dentoalveolar structures (supporting bone of the tooth or the jaw bones) and your surgeon performed an incision to drain the abscess from the dentoalveolar support structures, you will have to report an abscess drainage of the dentoalveolar structures. In such a case, you will have to report 41800 (Drainage of abscess, cyst, hematoma from dentoalveolar structures).

However, if the abscess is not localized in the dentoalveolar supporting structures and has spread to the submandibular space (as in the case of a cellulitis), you will then have to report 41008 (Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular space). If the abscess is in other spaces and your surgeon is using an intraoral approach, you will have to report an appropriate CPT® code from the 41000-41009 range. For an extraoral approach, report a code from 41015-41018 range.

Since from the procedural notes it appears that your surgeon has drained an abscess from the dentoalveolar structures, you will have to report 41800 in this case.

Don’t forget: To support the medical necessity of the procedure, you will need to report an appropriate ICD-10 code in addition to the procedural code. In this case, you will have to report K04.7 (Periapical abscess without sinus).