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ICD-10 Guide
ICD-10 CodesChapter 11: Diseases of the digestive systemK04

K04

Non-billable

Diseases of pulp and periapical tissues

Chapter 11:Diseases of the digestive system

BILLABLE STATUSNo
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/06/2025

Code Description

ICD-10 K04 is a used to indicate a diagnosis of diseases of pulp and periapical tissues.

Key Diagnostic Point:

K04 encompasses diseases of the pulp and periapical tissues, primarily affecting the dental pulp, which is the innermost part of the tooth containing nerves and blood vessels. Clinical presentations often include toothache, sensitivity to temperature, and swelling in the gums. The anatomy involved includes the dental pulp, periapical tissues, and surrounding structures such as the alveolar bone. Disease progression can lead to pulp necrosis, abscess formation, and potential tooth loss if untreated. Diagnostic considerations include clinical examination, radiographic imaging to assess periapical changes, and pulp vitality tests. Conditions such as pulpitis (inflammation of the pulp), periapical abscess, and periapical granuloma fall under this code, necessitating a thorough understanding of dental anatomy and pathology for accurate diagnosis and treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity: Requires understanding of dental anatomy and pathology.
  • Treatment complexity: May involve endodontic procedures, which can vary in difficulty.
  • Documentation requirements: Detailed clinical notes and imaging reports are essential.
  • Coding specificity: Requires precise coding to differentiate between types of pulp and periapical diseases.

Audit Risk Factors

  • Common coding errors: Misclassification of conditions or failure to document specific findings.
  • Documentation gaps: Incomplete clinical notes or lack of imaging support.
  • Billing challenges: Denials due to insufficient documentation or incorrect code selection.

Specialty Focus

Medical Specialties

Dentistry

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Oral and Maxillofacial Surgery

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Related CPT Codes

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The clinical significance of K04 lies in its potential to affect oral health and overall well-being. Untreated pulp and periapical diseases can lead to systemic complications, increased healthcare utilization, and a decline in quality of life. Understanding the epidemiology of these conditions can help healthcare providers implement preventive measures and improve patient outcomes.

ICD-9 vs ICD-10

The clinical significance of K04 lies in its potential to affect oral health and overall well-being. Untreated pulp and periapical diseases can lead to systemic complications, increased healthcare utilization, and a decline in quality of life. Understanding the epidemiology of these conditions can help healthcare providers implement preventive measures and improve patient outcomes.

Reimbursement & Billing Impact

Reimbursement considerations include the complexity of the procedure performed, the necessity of imaging studies, and the patient's insurance coverage. Common denials may arise from insufficient documentation or incorrect coding. Best practices include ensuring that all clinical findings are documented and that the treatment plan aligns with the diagnosis to support claims effectively.

Resources

Clinical References

  • •
    ICD-10 Official Guidelines for K00-K99
  • •
    Clinical Documentation Requirements

Coding & Billing References

  • •
    ICD-10 Official Guidelines for K00-K99
  • •
    Clinical Documentation Requirements

Frequently Asked Questions

What specific conditions are covered by K04?

K04 covers conditions such as acute and chronic pulpitis, periapical abscess, and periapical granuloma. Each condition has specific diagnostic criteria, including clinical symptoms and radiographic findings.

When should K04 be used instead of related codes?

K04 should be used when there is clear evidence of pulp or periapical tissue involvement. It is distinct from codes for periodontal diseases, which do not involve the pulp.

What documentation supports K04?

Documentation should include clinical examination findings, patient-reported symptoms, radiographic images showing periapical changes, and treatment plans. Detailed notes on the patient's dental history are also essential.