Periapical abscess with sinus

This code signifies an infection originating at the apex of a tooth root, characterized by the formation of pus and the presence of a draining tract (sinus). This condition typically arises from untreated dental caries or trauma, leading to pulpal necrosis and subsequent periapical inflammation.

Apply this code when documentation clearly indicates a periapical abscess with an associated sinus tract, which may be intraoral or extraoral. Supporting documentation includes clinical findings such as swelling, pain, purulent discharge, and radiographic evidence of a periapical radiolucency.

• Differentiate from a periapical abscess without a sinus (K04.7) or an acute apical periodontitis (K04.4).
• Ensure the documentation specifies the presence of a "sinus" or "fistula" to support this specific code.
• Consider sequencing this code as a primary diagnosis when it is the main reason for the patient's encounter.