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When is D7981 used?
The D7981 dental code applies to the surgical removal of a salivary gland and requires comprehensive documentation. This CDT code is utilized when a dental professional extracts a salivary gland—usually because of persistent infection, blockage, or tumor-like growths that cannot be treated with less invasive methods. It's crucial to understand that D7981 does not cover simple removal of minor salivary gland tissue or basic incision and drainage procedures; these situations may need different codes, such as D7910 for basic lesion removal. Always verify the medical necessity and make sure the procedure aligns with the code definition before choosing D7981.
D7981 Charting and Clinical Use
Accurate documentation is essential when submitting claims for D7981. Your patient records should contain:
The patient's condition and symptoms (such as ongoing sialadenitis, blocked salivary stones, or possible tumor).
X-rays or diagnostic studies that justify the need for gland extraction.
A comprehensive surgical report describing which gland was removed (parotid, submandibular, or sublingual), the surgical method used, and any complications or discoveries.
Post-surgery care guidelines and follow-up schedule.
Typical clinical situations include ongoing infection that doesn't respond to standard treatment, repeated blockages from stones, or confirmed tumors through biopsy. In all cases, complete documentation demonstrates the medical need for the surgery and supports your insurance claim.
Billing and Insurance Considerations
Processing claims for D7981 needs careful attention to secure quick payment and reduce claim rejections:
Prior approval: Most dental and medical insurance plans need prior approval for gland removal. Provide patient records, imaging studies, and a clear explanation for the surgery.
Dual coding: Because salivary gland removal is often viewed as a medical treatment, be ready to use the matching CPT code if the patient's dental insurance refuses coverage. Work with the patient's medical insurance when necessary.
Supporting documents: Always include backup materials (X-rays, lab reports, surgical notes) when submitting your claim.
Claim tracking: Watch your billing reports for timely payments. If insurance paperwork shows a denial, check the reason and file an appeal with extra documentation if needed.
Well-organized dental practices create systems for insurance checking, prior approvals, and prompt claim filing to get the best payment for complex surgical procedures like D7981.
How dental practices use D7981
Practice Example: A 52-year-old patient comes in with repeated swelling and discomfort in the right lower jaw area. Scans show a large stone blocking the duct, causing ongoing infection. Standard treatments haven't worked. The oral surgeon records the condition, examines the scans, and gets insurance approval. The gland is removed using general anesthesia, with complete surgical notes and lab results provided. The claim is submitted using D7981, with all necessary paperwork included. The dental practice checks with insurance, answers requests for more information, and eventually receives payment after a successful review process.
This practical example shows how important complete records, prior approval, and careful follow-up are when billing for D7981.
Common Questions
What complications and risks should be considered when performing salivary gland excision under code D7981?
Salivary gland excision carries several potential risks including nerve damage (particularly to facial or lingual nerves), bleeding, infection, hematoma formation, and scar tissue development. Patients may occasionally experience ongoing dry mouth symptoms or changes in taste sensation. Maintaining precise surgical techniques and comprehensive documentation of any complications is essential for patient care and proper billing procedures.
Does D7981 apply to partial salivary gland removal or only complete gland excision?
Code D7981 is specifically designated for complete salivary gland excision procedures. When only partial gland removal is performed, alternative coding may be required. It's essential to carefully review clinical documentation and current coding guidelines to verify that the actual procedure corresponds with the submitted code.
What preoperative documentation and patient preparation steps are necessary before using D7981?
Essential preoperative documentation includes obtaining informed patient consent, completing pre-surgical imaging studies, conducting necessary laboratory work, and thoroughly reviewing the patient's medical history. This comprehensive documentation demonstrates medical necessity and facilitates insurance authorization processes. Recording previous unsuccessful conservative treatment attempts is also crucial for justifying the surgical intervention.