Billing and Coding Canker Sores, a Common Oral Condition

A canker sore, a type of mouth ulcer, presents as a painful open sore within the mouth. It is one of the most prevalent conditions that a dental billing company helps dental professionals report on claims. Also known as aphthous ulcers, canker sores typically appear on the inner surfaces of the cheeks and lips, the tongue, the upper mouth surface, and the base of the gums. Approximately 20% of the U.S. population has had a canker sore at least once in their lifetime, according to Cleveland Clinic.

Causes and Types of Canker Sores

Canker sores can affect anyone, though they tend to be more prevalent among women and may have a genetic predisposition within families. These sores often occur without a clear cause, although they might be associated with viral infections or issues with the body’s immune system. Factors like mouth injuries from dental procedures, rough teeth cleaning, or accidentally biting the tongue or cheek can trigger their development. Additionally, emotional stress, deficiencies in certain vitamins and minerals (like iron, folic acid, or vitamin B-12), hormonal changes, and food allergies can also serve as triggers.

There are different types of canker sores:

• Simple canker sores: These are the most common and typically affect people aged 10-20. They’re small, oval-shaped with a red edge, occur 3-4 times a year, and heal within one or two weeks without scarring.
• Complex canker sores: Less common, larger, and more painful than simple ones. They’re round with defined borders but might have irregular edges when very large. These may stem from underlying conditions like compromised immunity, Crohn’s disease, or vitamin deficiency. They take longer to heal, up to six weeks, and may leave extensive scarring.
• Herpetiform canker sores: Caused by herpes virus infection, these sores are tiny with irregular edges. They develop later in life, often in clusters of 10-100 sores or may merge into one large ulcer. They typically heal within 1-2 weeks without scarring.

Signs and Symptoms

Canker sores may be preceded by local pain or a tingling sensation. Recognizable symptoms involve the emergence of one or more painful, red spots or bumps that evolve into open ulcers with a white or yellow center. The sores usually measure less than one-third inch or 1 centimeter across and take on a gray color during the healing process. Patients with severe canker sores may exhibit symptoms such as swollen lymph nodes, fever and a feeling of sluggishness. Canker sores are not contagious.

The pain associated with canker sores usually diminishes within 7 to 10 days, but complete healing can take anywhere from 1 to 3 weeks. Larger ulcers may require an extended duration (up to six weeks)to heal.

Diagnosis and Treatment

Diagnose canker sores do not require any tests. These sores can be easily identified through a visual examination. However, if the canker sores are severe and ongoing, tests may be required to check for other health problems. On a general basis, canker sores should be brought to the attention of a dentist or other specialist when they –

• Persist for more than 2 weeks without any improvement
• If the sores get worse (including while being treated with home remedies)
• If the sores are accompanied by other additional symptoms like fever, diarrhea, headache and skin rashes.
• If the sores recur (2-3 times a year or more) or are particularly numerous or severe

Diagnosis should be reported using the correct ICD-10 codes. The ICD-10 codes for canker sores include –

K12.0 Recurrent oral aphthae (billable)

Minor canker sores usually don’t require treatment and heal on their own. However, complex canker sores demand extensive medical care involving oral medications or cautery treatments. Simple canker sores can be managed using topical treatments, mouth rinses, and oral medications available in both over-the-counter and prescription forms. Common topical remedies include steroids for inflammation reduction and substances like lidocaine for pain alleviation. Additionally, physicians might recommend nutritional supplements to address canker sore flare-ups, especially for individuals with deficiency in iron, vitamin B-12, folate, and zinc.

Cautery of canker sores involves using an instrument or chemical substance to burn, sear or destroy tissue. Mayo Clinic lists two options:

• Chemically cauterizing canker sores using debacterol, a topical solution, may reduce healing time to about a week.
• Silver nitrate, another option for chemical cautery of canker sores, which may help relieve canker sore pain

For canker sores, the CPT codes for procedures might include:

• D0120 – Periodic oral evaluation – This code is used for a comprehensive assessment of a patient’s oral health, which could include an examination for canker sores.
• D9310 – Consultation – Used for consultations specifically related to oral health issues such as canker sores.
• D9311 – Consultation for a patient of record (usually involves advising on the management of canker sores for an existing patient).
• D9610 – Therapeutic parenteral drug, single administration – This code might apply if medication is administered to treat severe or persistent canker sores.
• D9940 – Occlusal guard by report – Sometimes recommended for preventing oral trauma for patients with severe or recurrent canker sores.
• D9420 – Counseling for the control and prevention of oral disease (could include counseling related to managing canker sores).

The CDT code for destruction of lesion(s) using cryo, laser or electro surgery is:

• D7465 destruction of lesion(s) by physical or chemical method

While there is no proven way to prevent canker sores, certain lifestyle modifications can reduce your risk. This includes avoiding acidic, salty or spicy foods, practicing good oral hygiene, brush twice a day using a soft-bristled toothbrush, flossing once daily. Addressing potential nutritional deficiencies and reducing stress can also help.

Documentation and Billing Guidance

Here are some general documentation and billing tips for canker sores:

• Ensure accurate and detailed documentation of the patient’s symptoms, examination findings, and treatment provided for canker sores.
• Use the appropriate codes based on the services rendered and the complexity of the case.
• Verify the medical billing codes for accuracy before submitting claims to insurance companies.
• Be aware of specific insurance guidelines or requirements for billing oral health procedures and treatments.

Consulting with an experienced provider of dental billing services can ensure precise guidance on billing and coding practices. Dental billing companies have certified medical coders and billing specialists who are also knowledgeable about insurance companies’ regulations and policies, and will ensure accurate claim submission to optimize physician reimbursement.

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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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