F YOUR OFFICE IS PROVIDING oral cancer screenings you may be seeing the following example:

Your clinician reviews a 59-year-old male patient with complaints of whitish discoloration in the area of the gums and the cheeks. The patient had a history of a pack-a-day smoking and moderate alcohol consumption from the past 25 years. The patient had recently noticed the discoloration when examining his mouth in the mirror and was worried because of his smoking habits and approached your clinician even though there were no other symptoms.

Upon examination, your clinician notes the presence of whitish lesion on both sides of the buccal mucosa that extended to the area of the gingival. The lesion appeared to be slightly elevated and was palpable. There seemed to be no symptom of pain or tenderness. 

Suspecting a diagnosis of leukoplakia, your surgeon obtained a biopsy specimen of the lesion and sent it to the lab for histological studies that confirmed a diagnosis of oral leukoplakia.

What to report: You report the biopsy performed with 40808 (Biopsy, vestibule of mouth). You report the diagnosis with K13.21 if you are using ICD-10 codes or report 528.6 if you are using ICD-9 codes. 

There are many tests available to supply this diagnosis such as Oral DNA, Or a brush biopsy.  Many surgeons like to have a lab test before you send them for the biopsy.  What does this mean?  Try using some of the non-surgical tests prior to the surgery patients will appreciate your input and concern.

If you want information on Oral DNA, or Brush Biopsy tests,  please contact me I will provide you with a direct person to speak with.

Christine Taxin
36 Abington Avenue
Ardsley New York 10502
United States of America