A patient presents in pain and is complaining about swelling around one particular tooth.  The emergency evaluation focused on the patient’s chief complaint, probing depths were recorded and two periapical images were produced.  Swelling was adjacent to #3 and the sulcus gushed a purulent mixture of blood and pus upon probing.

The patient was treated for a periodontal abscess by debridement and draining through the sulcus, irrigating the pocket with chlorhexidine and prescribing the patient an antibiotic.

How would you code this procedure?

Since the evaluation was both “problem-focused” and limited to the patient’s complaint, the appropriate codes for the diagnostic procedures would be:

• D0140 limited oral evaluation-problem focused

• D0220 intraoral-periapical first radiographic image

• D0230 intraoral-periapical each additional radiographic image

In this scenario, there are a few different codes that might be used to document the operative services (either alone or in combination).  Some possibilities are:

D9110 palliative (emergency) treatment of dental pain-minor procedure.  Typically this is reported on a “per visit” basis for emergency treatment of dental pain.

Use of this code to document the service provided may require a narrative to describe the exact treatment rendered.  It may be the most appropriate code to use in this case.

You may also consider:

D7510 incision and drainage of abscess – intraoral soft tissue  Involves incision through mucosa, including periodontal origins.

Dr. Joan Monaco will be presenting the following courses at Resource Day this October:

• Bullet Proofing Your Records
• Coding Challenges with Dr. Joan