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2025 ICD-10-CM code K13.21

Leukoplakia of the oral mucosa, including the tongue.

Follow all official ICD-10-CM coding guidelines provided by the Centers for Medicare & Medicaid Services (CMS) and the World Health Organization (WHO).

ICD-10 codes do not use modifiers.

Medical necessity for diagnostic and therapeutic interventions for leukoplakia is established by the presence of oral lesions that cannot be otherwise explained, raise suspicion of malignancy, and necessitate tissue biopsy for definitive diagnosis and possibly treatment.The clinical suspicion is justified by a thorough oral exam and the patient’s history.

The clinical responsibility for managing leukoplakia typically falls upon dentists, oral surgeons, or otolaryngologists.Responsibilities include conducting a thorough oral examination, obtaining biopsies for histopathological examination, and managing the patient’s treatment, which may include surgical removal of the lesions.Ongoing monitoring is crucial due to the potential for malignant transformation.

IMPORTANT:Consider additional codes to specify related conditions such as alcohol abuse (F10.-), tobacco use (Z72.0), or other contributing factors.This code excludes hairy leukoplakia (K13.3).

In simple words: This code describes leukoplakia, which is a condition causing painless white patches inside your mouth, including on your tongue. These patches are usually caused by irritation and may increase your risk for mouth cancer. Your doctor will need to check these patches to make sure they are not cancerous.

K13.21 in the ICD-10-CM classification system denotes leukoplakia of the oral mucosa, specifically affecting the tongue.This code is used to classify a condition characterized by the presence of white patches on the mucous membrane of the mouth, including the tongue.The patches are typically thick, cannot be scraped off, and may exhibit variations in texture and appearance.The etiology is often linked to chronic irritation from factors such as tobacco use, alcohol consumption, or poorly fitting dental appliances. While generally not painful, leukoplakia carries an increased risk of malignant transformation into oral cancer.A definitive diagnosis requires a biopsy to rule out other conditions and confirm the presence of leukoplakia.

Example 1: A 60-year-old male patient presents with a white patch on his tongue that he has noticed for several months.The patch is non-removable and relatively asymptomatic. The dentist performs a biopsy and confirms the diagnosis of leukoplakia of the tongue (K13.21)., A 45-year-old female patient with a history of heavy smoking and alcohol consumption presents with multiple white patches on her buccal mucosa and tongue. The dentist performs a thorough examination and orders a biopsy which leads to a diagnosis of leukoplakia (K13.21).The patient is advised to quit smoking and reduce alcohol intake., A 70-year-old male patient who wears ill-fitting dentures presents with a white lesion on his lower gum line. The dentist performs an evaluation, removes the ill-fitting denture, and performs a biopsy which confirms leukoplakia (K13.21).New dentures are ordered and the patient is monitored for recurrence.

Complete medical history, including smoking and alcohol consumption. Detailed oral examination findings, noting location, size, texture, and appearance of lesions. Histopathological report of the biopsy confirming the diagnosis.Images (photography or digital) of the lesion.Documentation of patient counseling on risk factors and follow-up care.

** Regular follow-up examinations are critical for patients with leukoplakia due to the risk of malignant transformation.The prognosis is generally good with early diagnosis and treatment, but the risk of recurrence remains.

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