Wiki Foreign Body Removal Floor of Mouth

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lapcpc

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Physician took a patient to surgery for removal of a titanium screw from the floor of mouth. Looking for CPT code for procedure.

"The radiographic films revealed that the patient had a lesion approximately 1/2 inch, approximately 1.5 cm below the floor of mouth, just slightly to the mid-line. An incision was made in the lingual frenulum area and it was approximately 1.5 cm to 2 cm in length. Then the floor of the mouth musculature was divided and the dissection carried down through the scar tissue, since the patient had had previous genioglossus surgery, down to the foreign body which was an extruded titanium screw, which had become extruded from the medial aspect of the symphysis. The patient actually had a small divot and radiolucency in the jaw where this titanium screw had been extruded. Very carefully, the screw was removed with its associated Prolene, which was still approx. 3 cm in length and removed from the floor of mouth"

Should I use the unlisted code 41599 (unlisted procedure, tongue, floor of mouth) - My initial thought was 40805, but that seems to be more for the vestibule of mouth (nothing in that description says floor of mouth).

Thanks for any and all help

Lori
 
I would use the unlisted procedure code, it's more accurate. The 40805 is very specific to the vestibule, where the unlisted can be for a different part.
 
I would code this with CPT code 20680 - Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate). This code is not site specific. In fact, AAPC coder gives an illustration of a femur bone as an example for this code (see attached).

View attachment CPT-CODE-20680.pdf

Hope that helps!
 
Outpatient Coding Specialis

I am new to dental coding, so if a dentist says multiple decayed teeth with PERIAPICAL RADIOLUCENCY, what is PERICAPICAL RADIOLUCENCY and is there a diagnosis code for this.
 
Totally agree with JenniferB7, CPT 20680 is correct, we used this all the time when I worked ENT (27 yrs) for the removal of mandibular plating or extruded screws or pins; it is appropriate for any anatomical site, if you notice it is listed under "Introduction or Removal" in the beginning section of Surgery/Musculoskeletal System.

Jennifer B.
Coding Analyst
 
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