Rank: Guest
Joined: 9/8/2012(UTC)
Posts: 16,925
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Could use some help cross coding!
Here’s the background:
Patient had an injury as a child, resulting in a "root canal on a front tooth & all 4 front teeth have no roots"
At a recent unrelated surgery, teeth were damaged during intubation and are now visibly loose, affecting speech & eating.
Our oral surgeon is recommending removal of #7,8,9,10 with socket preservation x4 & tissue regeneration with implants after healing.
“CT scan reveals bone within the buccal palatal dimension of between 3 & 4 mm. There is advance root resorption”…” inadequate bone for implant placement “ (doctor indicated onlay graft but I reminded the staff that is only for edentulous areas).
Here’s what I’ve got so far & would appreciate any guidance if I’m missing anything:
76497 for the CT Scan
21249 implants
21210 -51 for the grafts
41870 tissue graft regeneration
Based on my provider & the notes from the patient & the doctor where injury occurred the ICD-10 I have determined:
K03.30 Pathological resorption of teeth
K08.419 Partial loss of teeth due to trauma, unspecified
R43.9 Disturbances of smell and taste
Y65.8 Other specified misadventures during surgical and medical care
Place was a provider’s office with attached surgery center but I have these for location:
Y92.530 Ambulatory surgery center as the place of occurrence of external cause OR
Y92.531 Health care provider office as place of the external cause
(but I’m not sure about this, a website I was on regarding the rules for order of diagnosis stated on one code from category & should be recorded on a medical record)
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Rank: Administration
Joined: 11/21/2012(UTC)
Posts: 1,611
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Hi Guest!
Great job, your coding looks solid to me!
The only thing I may do differently based on what you described, is instead of:
K08.419 Partial loss of teeth due to trauma, unspecified
You may consider:
S03.2XXA - Dislocation of tooth, initial encounter
Or if there were any fractured teeth:
S02.5XXA - Fracture of tooth (traumatic), initial encounter for closed fracture
S02.5XXB - Fracture of tooth (traumatic), initial encounter for open fracture
It sounds like there may be some atrophy of the maxilla as well? If so:
K08.24 - Minimal atrophy of maxilla
K08.25 - Moderate atrophy of the maxilla
K08.26 - Severe atrophy of the maxilla
and perhaps also use G89.11 (Acute pain due to trauma) as applicable.
Hope this helps!
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Rank: Guest
Joined: 9/8/2012(UTC)
Posts: 16,925
Was thanked: 16 time(s) in 15 post(s)
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Thanks! Cross coding is my least favorite thing to do. I will check but I don't think any of the teeth were fractured. I appreciate your response, it's a great help!!
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