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ICD-10 Guide
ICD-10 CodesC04.1

C04.1

Billable

Malignant neoplasm of lateral floor of mouth

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 C04.1 is a billable code used to indicate a diagnosis of malignant neoplasm of lateral floor of mouth.

Key Diagnostic Point:

The lateral floor of the mouth is a critical area within the oral cavity, bordered by the mandible and the tongue. Malignant neoplasms in this region can arise from various tissues, including squamous cells, salivary glands, and connective tissues. These tumors may present as asymptomatic lesions or with symptoms such as pain, difficulty swallowing, or changes in speech. Risk factors include tobacco use, alcohol consumption, and HPV infection. Diagnosis typically involves a thorough clinical examination, imaging studies, and biopsy to confirm malignancy. Treatment often requires a multidisciplinary approach, including surgical resection, radiation therapy, and chemotherapy, depending on the tumor's stage and location. Dental considerations are paramount, as patients may experience complications such as xerostomia (dry mouth) and osteoradionecrosis following treatment. Regular dental evaluations and preventive care are essential for maintaining oral health in these patients.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and symptoms of oral cavity malignancies
  • Need for precise anatomical localization in documentation
  • Potential for overlapping symptoms with benign conditions
  • Multidisciplinary treatment approaches requiring coordinated documentation

Audit Risk Factors

  • Inadequate documentation of tumor characteristics
  • Failure to document multidisciplinary treatment approaches
  • Misclassification of tumor stage
  • Lack of follow-up documentation post-treatment

Specialty Focus

Medical Specialties

Oncology

Documentation Requirements

Detailed pathology reports, imaging studies, and treatment plans must be documented.

Common Clinical Scenarios

Patients presenting with advanced lesions requiring surgical intervention or palliative care.

Billing Considerations

Ensure accurate staging and treatment documentation to support coding.

Dentistry

Documentation Requirements

Comprehensive dental evaluations and treatment plans, including management of complications.

Common Clinical Scenarios

Patients undergoing radiation therapy requiring dental care to manage xerostomia and prevent osteoradionecrosis.

Billing Considerations

Coordination with oncology for comprehensive patient management.

Coding Guidelines

Inclusion Criteria

Use C04.1 When
  • Follow the official ICD
  • CM guidelines for coding neoplasms, including the need for specificity in location and type

Exclusion Criteria

Do NOT use C04.1 When
  • Ensure compliance with inclusion and exclusion criteria for accurate coding

Related ICD-10 Codes

Related CPT Codes

21045CPT Code

Excision, malignant lesion, face, ears, eyelids, scalp, neck

Clinical Scenario

Used for surgical excision of the malignant neoplasm.

Documentation Requirements

Surgical notes detailing the excision and margins.

Specialty Considerations

Oncology and surgery must coordinate for accurate coding.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of oral cavity malignancies, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of oral cavity malignancies, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

Resources

Clinical References

  • •
    American Cancer Society - Oral Cavity Cancer

Coding & Billing References

  • •
    American Cancer Society - Oral Cavity Cancer

Frequently Asked Questions

What are the common symptoms of a malignant neoplasm of the lateral floor of the mouth?

Common symptoms include pain, difficulty swallowing, changes in speech, and the presence of a lesion or ulcer in the area.