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#1 Posted : Tuesday, January 12, 2021 4:03:58 PM(UTC)

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I have a 21-year-old patient that presents with pain and pressure related to a previous jaw trauma. The patient was beaten by a group of men. #22 and 23 had root canals 6 months after surgery in an attempt to relieve continuous pain. The current exam shows metal plate hardware anterior mandible. PARL at #21 and widened PDL at #23.

A retreat root canal would have low success. Planning the removal of #22 and #23 due to widened PDL and plan for implant replacement. Removal of hardware in the anterior mandible.

Question is what CPT and ICD9 codes can be used to have as much as possible covered from medical insurance?

The responses are greatly appreciated.

Edited by user Tuesday, January 12, 2021 7:26:55 PM(UTC)  | Reason: add details for coding

#2 Posted : Thursday, January 14, 2021 12:07:24 PM(UTC)

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Hi Guest!

Based on what you described, here are some coding options for you :)

ICD-10 diagnosis coding options:

M27.2 - Inflammatory conditions of jaws
R68.84 - Jaw pain
G89.21 - Chronic pain due to trauma
Y04.0XXS - Assault by unarmed brawl or fight, sequela

Procedure (CPT) coding options:

As for the CPT code for extractions, there is actually not direct crosscodes we are aware of, so you can either bill the "D" code on the medical claim (many insurers these days will process "D" codes when they are medically necessary services), or you can use the CPT code below and include a narrative report describing the procedure:
41899 - Unlisted procedure, dentoalveolar structures

For the removal of hardware in the anterior mandible:

20680 - Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)

For the implants:
21248 - Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial(3 or less)
21249 - Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete (4 or more)

Hope this helps!
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