If your otolaryngologist diagnoses a benign tumor in a patient’s mouth, she hopefully pinpoints the tumor location to help make your coding more accurate. When you don’t have a specific location, you have two code choices under ICD-10 instead of a single catch-all code as in ICD-9.
ICD-9 structure: When you still coded by ICD-9, you would report 210.4 (Benign neoplasm of other and unspecified parts of mouth) for patients diagnosed with tumors of the mouth. This code included the following anatomic sites:
ICD-10 changes: With ICD-10 in effect, your options have expanded from 210.4 to two D codes with fifth characters that identify unspecified and other parts of mouth from where the tumor grows. These news codes are:
Documentation: Take note of your provider’s documentation of symptoms, which may depend on the cell type of origin, size and location of the growth, and the organ system involved. The patient may report noticing a lump or skin change. If the tumor disturbs the nerves, it can cause pain or disorders (such as dizziness, weakness, or headaches). Make sure the physician confirms in her notes that her diagnosis is benign.
Coder tips: After your health care provider has performed a physical exam of the mouth, she usually completes a biopsy (i.e., 40808, Biopsy, vestibule of mouth) to confirm that the growth is not cancerous. Depending on the location and size of the tumor, surgery may be recommended, which often completely removes the tumor.
About the diagnosis: Many different cell types make up different structures of the mouth. Cancer occurs when normal cells undergo a transformation whereby they grow and multiply without normal controls. As the cells multiply, they form small abnormalities called lesions. Eventually, they form a mass called a tumor. If the tumor is benign, then it is not cancerous. The general rule for benign tumors is that although they may grow and penetrate below the surface layer of tissue, they do not spread by metastasis to other parts of the body.