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)
