Documenting and Coding Leukoplakia – A Common Mouth Condition

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Leukoplakia refers to a condition wherein thick, white or grayish patches or lesions appear inside the mouth. Typically, these white or grayish patches develop on the bottom of the patient’s mouth (sometimes on the tongue and mucosa), inside the cheeks and even on the patient’s lips – which is caused by excess cell growth. These lesions can vary in appearance but are typically white or gray and have thick, raised edges with a hard surface. There is no single or definitive cause for leukoplakia. Tobacco use of any kind is one of the most common influencing factors in the development of the condition. In fact, people who smoke are six times more likely to develop leukoplakia. Mild cases of leukoplakia patches are harmless and often get cured on their own. On the other hand, more severe cases may be linked to oral cancer and must be treated promptly. Regular dental care habits can help prevent its reoccurrence. As medical billing and coding for this condition involves several challenges, physicians need to have adequate knowledge on how to document the procedures correctly in the medical records. Outsourced services of a reliable medical billing company would be a perfect option as this can help physicians ensure timely claim filing for accurate reimbursement.

Generally, most cases of leukoplakia lesions are noncancerous, though some show early signs of cancer. The condition is marked by unusual-looking patches inside the patient’s mouth. These patches can have an irregular shape, are white or gray in color, thick, with a hard or raised surface, hairy/fuzzy (hairy leukoplakia only) and with red spots (in rare cases). These patches cannot be rubbed or scraped away. These may take several weeks to develop and are rarely painful. Red spots, in most cases, may be a potential sign of cancer. Hence, it is important to consult a dentist or a primary care professional as soon as unusual, persistent changes are noticed.

Causes and Symptoms

As mentioned above, the exact cause of leukoplakia is unknown. Chronic irritation from tobacco and other related products – whether smoked, dipped or chewed can be considered one of the top causes. The lesions or patches commonly appear inside the mouth of chain smokers or users of smokeless tobacco products. Other associated causes include – uneven teeth, injury to the inside of the cheek (such as from biting), dentures (especially if improperly fitted), jagged, broken or sharp teeth rubbing on the tongue surface, inflammatory conditions of the body, sun exposure to the lips and long-term alcohol use. Another common type of leukoplakia called hairy leukoplakia (also called oral hairy leukoplakia) primarily affects people whose immune systems have been weakened by disease, especially HIV/AIDS.

Leukoplakia is not usually painful and may go unnoticed for a while. Most cases occur in men in the age group of 50 -70 years. In most cases, less than 1 percent of cases are seen in patients under the age of 30 years. Common symptoms include –

  • Appearance of raised, red lesions (called erythroplakia)
  • White or grayish patches (that cannot be wiped or scraped away)
  • Irregular or flat-textured
  • Thickened or hardened in areas

Diagnosing and Treating Leukoplakia

Diagnosis of symptoms usually starts with an oral exam. As part of the oral exam, the dentist or primary physician may examine the patches in the patient’s mouth and attempt to wipe off the white or gray patches in order to confirm whether the patches are leukoplakia. In some cases, people mistake these patches as the condition for oral thrush – a yeast infection of the mouth. Dentists may also evaluate the patient’s previous medical history and other risk factors for this condition. They may need to do other tests to confirm the cause of the spots as this helps them to recommend a treatment modality that prevents the reoccurrences of patches. If the condition of leukoplakia is confirmed, the dentist will most probably test for early signs of cancer by performing an oral biopsy and excisional biopsy.

Treatment for this condition becomes most successful when a lesion is found early and treated early, when it is small. Regular checkups are important to inspect the patient’s mouth for areas that look quite abnormal. In most cases, these grey or white patches improve on their own and don’t require any specific treatment. However, if the patient’s condition is related to irritation from a dental problem, the dentist may be able to treat this issue.

If the lesions show early signs of cancer, the treatment may involve removing patches immediately as this helps prevent the cancer cells from spreading. Patches can be removed by using laser therapy, a scalpel, or a freezing procedure. Antiviral medications may be prescribed which can suppress the Epstein-Barr virus – the cause of hairy leukoplakia. An experienced medical coding company can help physicians report the correct billing codes. ICD-10 codes used to indicate a diagnosis of this condition include –

K13 – Other diseases of lip and oral mucosa

  • K13.0 – Diseases of lips
  • K13.1 – Cheek and lip biting
  • K13.2 – Leukoplakia and other disturbances of oral epithelium, including tongue
    • K13.21 – Leukoplakia of oral mucosa, including tongue
    • K13.22 – Minimal keratinized residual ridge mucosa
    • K13.23 – Excessive keratinized residual ridge mucosa
    • K13.24 – Leukokeratosis nicotina palati
    • K13.29 – Other disturbances of oral epithelium, including tongue
  • K13.3 – Hairy leukoplakia

Practicing good oral hygiene and stopping activities that damage or stress the mouth lining are the best ways to manage and prevent leukoplakia. Some of the common prevention strategies include – stopping smoking or chewing tobacco, stopping the consumption of alcohol, eating antioxidant-rich foods (as these help deactivate irritants that cause patches), avoiding abrasive dental hygiene products, such as whiteners and rinses, keeping mouth wounds clean, attending routine dental exams and maintaining dental hygiene.

Medical billing and coding for dental disorders can be complex, as there are different documentation rules and medical codes associated with the conditions. Outsourcing is a great option to maximize efficiency in dental billing. Partnering with a reputable medical billing company can ensure proper dental eligibility verification and correct and timely medical billing and claims submission.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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