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My patient had cancer of the oropharynx followed by chemo and radiation. Patient now has xerostomia which caused moderate atrophy of maxilla resulting in loss of teeth, need for sinus lift, need for dental implants. What ICD 10 codes and diagnosis codes do I use for the sinus lift via lateral approach with bone and PRP? Thanks for your help!!!
Hi Guest! Based on what you described, here are some coding options for you: ICD-10 diagnosis: K08.25 – Moderate atrophy of the maxilla K08.491 – Partial loss of teeth due to other specified cause, class I K08.492 – Partial loss of teeth due to other specified cause, class II K08.493 – Partial loss of teeth due to other specified cause, class III K08.494 – Partial loss of teeth due to other specified cause, class IV K08.499 – Partial loss of teeth due to other specified cause, unspecified class Z85.818 – Personal history of malignant neoplasm of other sites of lip, oral cavity, and pharynx Z92.3 – Personal history of irradiation K11.7 – Disturbances of salivary secretion Procedure codes: 21210 – graft, bone; nasal, maxillary, or malar areas *use -52 modifier for reduced services when bone is not obtained from the patient 21248 – Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial(3or less) 21249 – Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete (4 or more) 0232T — Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed. Hope this helps!
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