Oral Tissue Biopsy

In the world of dentistry, the ability to accurately diagnose oral conditions is paramount to effective treatment and patient care. Amidst the array of diagnostic tools available, oral tissue biopsy stands out as a crucial procedure that enables dentists to delve deeper into suspicious lesions, ulcers, or growths within the oral cavity.

After a thorough inspection of the oral cavity, any abnormalities of the oral tissue should be documented in the patient's record, and a differential diagnosis should be developed. If lesions related to trauma, infection, or inflammation have not resolved after two weeks, they must be biopsied when all the local irritants have been removed, and treatment has been unsuccessful. Based on their appearance, highly suspicious lesions unrelated to infection, trauma, or inflammation should be considered for immediate biopsy. A biopsy is the gold standard for unexplained oral mucosa abnormality. 

Submitting for insurance reimbursement may be through the patient’s dental insurance or medical insurance carrier. Below is a representative list of the applicable codes; other codes may apply to a particular situation. It is strongly advised that you research all available codes independently, but we hope this will help you get started.

Insurance Coding

Current Dental Terminology (CDT):

• D0431: adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities, including premalignant and malignant lesions, not to include cytology or biopsy procedures
• D0482: direct immunofluorescence a technique used to identify immunoreactants which are localized to the patient’s skin or mucous membranes
• D7285: code for biopsy of oral tissue (hard)
• D7286: code for biopsy of oral tissue (soft)
• D7287: code for exfoliative cytological sample collection
• D7288: code for brush biopsy- transepithelial sample collection
• D7284: excisional biopsy of minor salivary glands

Current Procedural Terminology (CPT; these are used to report procedures to a medical insurance company):

• 82397: Chemiluminescent assay
  40490: Biopsy of lip
• 40808: Biopsy, vestibule of mouth
• 41100: Biopsy of tongue, anterior two-thirds
• 41105: Biopsy of tongue, posterior two-thirds
• 40799: Unlisted procedure, lips
• 40899: Unlisted procedure, vestibule of mouth
• 41599: Unlisted procedure, tongue, floor of mouth
• 42100: Biopsy of palate, uvula

International Classification of Disease (ICD—10 – CM; when submitting a claim for dental services with a patient’s medical benefit plan, inform the carrier why a particular procedure may be medically necessary):

• Z01.21: Encounter for dental examination and cleaning with abnormal findings
• Z08: Encounter for follow-up examination after completed treatment for malignant neoplasm
• Z12.81:Encounter for screening for malignant neoplasm or oral cavity
• Z09: Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
• Z48.814: Encounter for the surgical aftercare following surgery on the teeth or oral cavity
• Z48.3: Aftercare following surgery for neoplasm
• Z71.2: Person consulting for explanation of examination or test findings
• Z12.81: Encounter for screening
• K13.1: Cheek and lip biting
• 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 palate
• K13.29: Other disturbances of oral epithelium, including tongue
• K13.3: Hairy leukoplakia
• K13.4: Granuloma and granuloma-like lesions of oral mucosa
• K13.5: Oral submucous fibrosis
• K13.6 Irritative hyperplasia of oral mucosa
• K13.7: Other lesions of oral mucosa
• K14.0: Glossitis
• K14.1: Geographic tongue
• K14.2: Median rhomboid glossitis
• K14.3: Hypertrophy of tongue papillae
• K14.4: Atrophy of tongue papillae
• K14.6: Glossodynia
• K14.8: Other diseases of tongue
• L43.9: Lichen planus, unspecified
• S00.511A: Abrasion of lip, initial encounter
• S00.511D: Abrasion of lip, subsequent encounter
• S00.511S: Abrasion of lip, sequela

The information provided here is not meant to be an exhaustive list of all potential medical and dental insurance claims and diagnosis codes. Instead, it aims to provide an overview of various dental CDT codes and available medical cross-codes. Using an appropriate code for each patient is solely the dentist’s responsibility. 

Both dental and medical billing procedures are complex. Training is recommended for practitioners new to one or both systems. You’ll want to determine which plan to bill first, as many dental insurance providers require claims considered medical to be billed to the appropriate medical plan first.

If you are not insured with DentistCare, A ProAssurance Program, feel free to complete this form to find out more about our coverage and get a quote!

References: CDT 2024 Current dental terminology, (2024); American Dental Association

The information contained on the DentistCare Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. All information contained on the blog is subject to change.