Periapical abscess with sinus
ICD-10 K04.6 is a billable code used to indicate a diagnosis of periapical abscess with sinus.
K04.6 refers to a periapical abscess with sinus, which is an infection that occurs at the apex of a tooth root, typically resulting from untreated dental caries or trauma. Clinically, patients may present with localized pain, swelling, and tenderness in the affected area, often accompanied by fever or malaise. The anatomy involved includes the tooth, surrounding alveolar bone, and the sinus tract that may develop as a result of the infection. Disease progression can lead to the formation of pus, which may drain through the sinus tract into the oral cavity or skin. Diagnostic considerations include clinical examination, radiographic imaging to assess the extent of the abscess, and possibly microbiological cultures to identify the causative organism. Treatment typically involves drainage of the abscess, root canal therapy, or extraction of the affected tooth, depending on the severity of the condition and the patient's overall health status.
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
K04.6 covers periapical abscesses that are specifically associated with a sinus tract. This includes cases where the infection has progressed to create a pathway for pus drainage, distinguishing it from other types of dental abscesses.
K04.6 should be used when there is clear evidence of a periapical abscess with an associated sinus tract. If the abscess is present without a sinus or is located in a different anatomical area, other codes such as K04.5 should be considered.
Documentation should include clinical findings such as pain assessment, swelling, and any imaging results that show the presence of an abscess and sinus tract. Treatment notes detailing drainage procedures or root canal therapy are also essential.
