Vision and Development screen billing overview


PCPs must perform a subjective vision screening (i.e., by history) at each well child visit. For asymptomatic children 3 years of age and older, an objective screening must occur as indicated on the AAP periodicity schedule. For children of any age, referral to an optometrist or ophthalmologist must be made if there are symptoms or other medical justification (e.g., parent/guardian has suspicions about poor vision in the child). The AAP requires a vision risk assessment at each well child visit. MDHHS requires vision testing at specific well child visits for children 3 years of age and older.


Due to behavior and comprehension ability of children younger than 3 years of age, the standard screening is subjective. An objective screening should begin at 3 years of age. An objective vision screening is accomplished using a standardized screening tool and may be performed on Medicaid eligible preschool-age children each year beginning at 3 years of age through 6 years of age by qualified Local Health Department (LHD) staff.

If the child is uncooperative, the screening should be re-administered within six months.

LHDs may provide objective vision screening services and accept referrals for screening from the PCP and from Head Start agencies. In an effort to promote communication with the child’s medical home, the objective vision screening results must be reported to the child’s PCP. In the event the LHD is unable to report the objective vision screening results to the child’s PCP, the LHD must clearly document why this could not be accomplished. If the LHD receives authorization, the results may be shared with the Head Start agency if that agency was the referral source.


A subjective vision screening must be performed at each well child visit; an objective screening shall be performed as indicated on the AAP periodicity schedule.


A vision screening is to be performed at 3, 4, 5, 6, 8, 10, 12, 15, and 18 years of age. A risk assessment is to be performed, with appropriate action to follow if positive, for newborns and during the ages of:

* 3 to 5 days

* 1 month

* 2 months

* 4 months

* 6 months

* 9 months

* 12 months

* 15 months

* 18 months

* 24 months
* 30 months

* 7 years

* 9 years

* 11 years

* 13 years

* 14 years

* 16 years

* 17 years

* 19 years

* 20 years


A developmental/behavioral assessment is required at each scheduled EPSDT well child visit from birth through adolescence as recommended by the AAP periodicity schedule. The PCP should screen all children for developmental and behavioral concerns, including engaging in risky behavior, using a validated and standardized screening tool as indicated by the AAP periodicity schedule.

A maximum of three objective standardized screenings may be performed in one day for the same beneficiary by a single provider. (Refer to the Billing & Reimbursement for Professionals Chapter for billing instructions.) If the screening is positive or suspected problems are observed, further evaluation must be completed by the PCP, or the child should be referred for a prompt follow-up assessment to identify any further health needs. The provider may administer additional screenings, surveillance, or assessments as described in the following subsections.


A developmental screening using an objective validated and standardized screening tool must be performed following the AAP periodicity schedule at 9, 18 and 30 (or 24) months of age, and during any other preventive health care well child visits when there are parent/guardian and/or provider concerns. Developmental screening may be accomplished by using a validated and standardized developmental screening tool such as the Ages and Stages Questionnaire (ASQ) or Parents’ Evaluation of Developmental Status (PEDS). If the screening is positive, PCPs should further evaluate the child, provide counseling, and refer the child as appropriate.



CMDS clinics are required to operate under the authority of hospitals or medical universities. Hospitals and medical universities requesting CMDS clinic designation must adhere to the requirements as stated in this policy and acquire approval and oversight from the CSHCS program. Hospitals and medical universities that administer CMDS clinics require a separate National Provider Identifier (NPI) number with which to enroll and submit claims for the CMDS clinic fee. CSHCS-approved organizations with responsibility for CMDS clinics must enroll through the online MDHHS CHAMPS Provider Enrollment (PE) subsystem to be reimbursed for clinic fees for services rendered to eligible beneficiaries. Each CMDS clinic must operate under the unique CMDS National Provider Identifier (NPI) held by the organization responsible for those CMDS clinics and must identify the providers who render the services in the CMDS clinic as affiliated providers. All affiliated providers whose services are directly reimbursable per MDHHS policy must be separately enrolled in CHAMPS and must also receive a beneficiary-specific authorization from CSHCS prior to the clinic billing for the clinic fees.


In addition to medical services, CMDS clinics provide:

* A single place and extended appointment for the family to be seen by their team of pediatric specialty providers as well as other appropriate health care professionals during each appointment;

* An environment where providers come to the family for the single appointment at the clinic as opposed to the family needing to set separate dates and times to go to each provider as in the usual service methodology;

* Same day, face-to-face care coordination by all of the providers who saw the beneficiary at each appointment allows for immediate discussion, negotiation, coordination and duty assignment. The family does not need to interpret information from one provider to the next which risks misunderstanding as in the usual service methodology;

* Development and upkeep of a coordinated and comprehensive plan of care (POC) and treatment for beneficiaries, including clear statements of current comprehensive assessment and ongoing treatment plans available to the entire team;

* Facilities that are tailored to the needs of children and their families; and

* Opportunities for the parent/beneficiary to participate in treatment planning, allowing for timely feedback and discussion of concerns with specialists and other health care professionals simultaneously when needed.

Services are provided as a comprehensive package by a team of pediatric specialty physicians and other appropriate health care professionals. CMDS clinic fees are not intended for sporadic users of the services available through CMDS clinics such as support services only. CMDS clinic fees are intended for the comprehensive, coordinated and integrated services that CMDS clinics provide to beneficiaries who return for and continue to use this full package of services.


Each CMDS clinic must have the following basic staff available to provide the unique service delivery available through a CMDS clinic model:

Medical Director A Medicaid-enrolled and CSHCS-approved physician currently licensed to practice under Michigan state law, with special training and demonstrated clinical experience related to the diagnoses followed by the specific CMDS clinic type. Physicians are expected to remain familiar with current developments and standards of treatment in their respective fields. If the medical director is not a pediatrician, a board certified pediatrician must be available and function within
the scope of current medical practice.

Physician A Medicaid-enrolled and CSHCS-authorized pediatric subspecialist, or adult subspecialist physician when serving adults, currently licensed to practice under Michigan state law with special training and demonstrated clinical experience related to the diagnoses treated by the specific CMDS clinic type. Physicians are expected to remain familiar with current developments and standards of treatment in their respective fields. Refer to the CMDS Clinic Guide, tables I and II, for subspecialty designations. The CMDS Clinic Guide is available on the MDHHS website. (Refer to the Directory Appendix for website information.)

Registered Nurse A Registered Nurse (RN) currently licensed to practice under Michigan state law and having a minimum of two years of pediatric nursing experience or adult nursing experience when serving adults. Certain CMDS clinics are exempt from this requirement (e.g., the Metabolic Diseases CMDS clinics) as long as they have the appropriate additional staff as required in the CMDS Clinic Guide.

Registered Dietitian A Registered Dietitian (RD) in possession of a master’s degree in human nutrition, public health, or a health-related field with an emphasis on nutrition, and two years of pediatric nutrition experience or adult nutrition experience whenserving adults in providing nutrition assessment, education and counseling. Social Worker A Licensed Master Social Worker (LMSW) or professional staff member in possession of a master’s degree in social work and two years of experience in counseling and providing service to children/youth, adults and their families.

Parent/Guardian and/or Beneficiary 

The parent/guardian and/or the beneficiary must be an actively participating team member in the development of the beneficiary’s comprehensive POC.

Additional Required Staff

Additional staffing requirements are based on clinic diagnosis type. Refer to the CMDS Clinic Guides on the MDHHS website for staffing requirements. (Refer to the Directory Appendix for website information.)


Beneficiaries with multiple, complex diagnoses may receive CMDS coordinated services from more than one CMDS clinic. However, the limits and numbers of CMDS clinic visit types indicate what the beneficiary is eligible to receive regardless of the number of CMDS clinics the beneficiary is accessing. Any CMDS clinic serving the beneficiary under the CMDS clinic process may submit claims for the appropriate clinic fee(s) up to the limit allowed per beneficiary. For example, there are 10 Support Visits allowed per beneficiary in a year. Any organization/clinic serving the beneficiary may bill for those support visits until the beneficiary limit has been reached. That might involve one CMDS clinic receiving reimbursement for all 10 of the Support Visits or a combination of CMDS clinics receiving reimbursement for some visits until the limit has been reached.

The CMDS clinics must document clinic visit levels to include the following:

* Support services must be indicated in the CMDS Plan of Care (POC) developed at a CMDS clinic Comprehensive Initial or Basic Evaluation visit or Management/Follow-up visit.

* The CMDS clinic must collaborate with other CMDS clinics the family/beneficiary may be using regarding which CMDS clinic is the lead CMDS clinic and how the fee billing will occur in coordination between the CMDS clinics that are both serving the same beneficiary.


The Initial Comprehensive Evaluation is performed during the CSHCS client’s first visit to the CMDS clinic. The medical team integrates assessments and recommendations and works with the family/beneficiary in the development of a coordinated and comprehensive POC and treatment for the beneficiary. The CMDS POC is required to be recorded. The CMDS clinic will communicate the written CMDS POC to the appropriate health care providers and the family/beneficiary. Written CMDS POCs may be provided to other appropriate health care providers for whom the parent/guardian/beneficiary has signed a medical release form. A copy of the CMDS POC is to be submitted to CSHCS medical consultants for review.

An Initial Comprehensive Evaluation visit must include the following:

* Physician specialist(s) and non-physician professionals examination or assessment of the beneficiary and submission of an established/confirmed diagnosis(es), identification of strengths and needs and, with family/beneficiary input, development of a course of action or plan for treatment;

* Integration of findings and recommendations at team conferences;

* Discussion of the medical findings and treatment recommendations with family/beneficiary in language the family/beneficiary can comprehend;

* Designation of identified staff to teach the family/beneficiary how to assist in the management of the beneficiary’s health problems if appropriate; and

* Compilation of an integrated CMDS POC from the findings of the various health care providers that includes:

* relevant history;

* medical findings by specialty;

* problem areas that may develop and for which the beneficiary should receive care;

* recommendations and prescriptions for braces, shoes, special equipment, medications, etc.;

* referral to physical therapy, speech-language therapy, occupational therapy, public health nurse, CMDS support services; and

* a description of how the CMDS POC will be implemented. Authorization and processes may differ per health plans and Fee-for-Service (FFS).

Reimbursement for the Initial Comprehensive Evaluation fee occurs only once per beneficiary per lifetime regardless of the number of diagnoses and/or CMDS clinics from which the beneficiary may be receiving services. Medical services continue to be billed as usual.


Basic and ongoing comprehensive evaluation is conducted with established CMDS patients. The evaluation(s) may include the entire CMDS clinic staff composition or asdeemed appropriate by each CMDS clinic Medical Director per visit and is documented in  the CMDS POC.

A basic and ongoing comprehensive evaluation may include the following activities:

* Comprehensive beneficiary assessment;

* Evaluation and identification of the beneficiary’s needs;

* Coordination of the beneficiary’s multi-disciplinary needs;

* Review and modification of the comprehensive CMDS POC;

* Assured implementation and follow-up; and

* Referrals to other professionals, resources, and services as applicable.

Reimbursement for the Basic and Ongoing Comprehensive Evaluation fee is provided for a maximum of three (3) visits per beneficiary, per 12-month CSHCS eligibility year regardless of the number of diagnoses or CMDS clinics the beneficiary may have.

Medical services continue to be billed as usual.


Management/follow-up visits to a CMDS clinic may be provided if they are recommended in the CMDS POC. In addition, a referral may be recommended based on a tertiary hospital inpatient discharge plan that was written within the previous 12 months of the referral. Every effort should be made to include all staff identified as participants in theCMDS POC or as recommended by the CMDS clinic Medical Director.

The management/follow-up visit may include:

* A physical exam by a pediatrician and/or physician subspecialist(s);

* Assessment by at least two of the clinic staff (in addition to the clinic physicians) designated for the clinic type;

* Follow-up on all components identified in the CMDS POC by appropriate staff;

* Update of condition and treatment, and revision of the CMDS POC; and

* Communication with the family/beneficiary, other providers, and other designated health care providers, including provision of copies of the CMDS POC to the family/beneficiary.

Reimbursement for the management/follow-up visit clinic fee is provided for a maximum of three (3) visits per beneficiary, per 12-month CSHCS eligibility year, regardless of the number of diagnoses or CMDS clinics the beneficiary may have. Medical services continue to be billed as usual.


CMDS clinics may provide support services. Services consists of counseling, specialized training, transition assistance and/or treatment. Support services must be ordered as part of the CMDS POC developed at a CMDS Clinic Initial Comprehensive Evaluation, Basic and Ongoing Comprehensive Evaluation, and/or Management/Follow-up Visit. CMDS clinic support services may be provided by any combination of one or more of the non-physician basic CMDS clinic staff to the family/beneficiary as outlined in the CMDS POC. Support services may be conducted by professional members of the team (i.e., nurses, dietitians, certified diabetes counselors, social workers or other clinical professional staff as appropriate). The presence of a physician is not required.

* The clinical encounter must be substantive with clinical information gathered, treatment recommendations provided, transition needs addressed and an update to the CMDS POC.

* The clinical content of the encounter is documented in the CMDS POC.

CMDS support service visits include and provide two different methods of delivery:

* Face-to-Face meetings between the appropriate clinic professional and thefamily/beneficiary; or

* Telephone meetings between the appropriate clinic professional and the family/beneficiary.

Reimbursement for support services clinic fees can be provided up to a maximum of ten (10) visits per beneficiary as a single method or as a combination of methods, per 12- month CSHCS eligibility year, regardless of the number of diagnoses or CMDS clinics the beneficiary may have. Medical services continue to be billed as usual.


CMDS clinics must establish and maintain an agreement with each Medicaid and MIChild Health Plan for health plan enrolled beneficiaries to ensure coordinated care planning and data sharing.

* CMDS clinics must establish a process for clinical staff to communicate with health plan staff on a regular basis to identify health plan enrollees using the CMDS clinic(s), review testing/assessment/screening results, treatment plans, CMDS POCs, and status of mutually served beneficiaries.

* CMDS clinics must collaborate with health plans on the development of referral procedures and effective means of communicating the need for beneficiary-specific referrals. For beneficiaries enrolled in a health plan, CMDS clinics must bill the Medicaid Health Plan (MHP) for medical services rendered according to the health plan billing rules.

The CMDS clinic fee is billed as a FFS claim through CHAMPS regardless of health plan status.

CMDS clinic fees must be billed according to instructions contained in the Billing & Reimbursement for Professionals Chapter of this Manual. CMDS clinics must bill clinic fees following Uniform Billing (UB) guidelines on the professional CMS-1500 claim format or the electronic Health Care Claim Professional (837) ASC X12N version 5010 information. CHAMPS NPI claim editing will be applied to the billing, rendering, supervising, attending, servicing and referring providers as applicable for payment.

icd 10 code hyponatremia - E87.0, E87.1

E87 Other disorders of fluid, electrolyte and acid-base balance Excludes1: diabetes insipidus (E23.2) electrolyte imbalance associated with hyperemesis gravidarum (O21.1) electrolyte imbalance following ectopic or molar pregnancy (O08.5) familial periodic paralysis (G72.3)

E87.0 Hyperosmolality and hypernatremia Sodium [Na] excess Sodium [Na] overload

Anhydration, anhydremia E86.0
- with
- - hypernatremia E87.0
- - hyponatremia E87.1
Anhydremia E86.0
- with
- - hypernatremia E87.0
- - hyponatremia E87.1

E87.1 Hypo-osmolality and hyponatremia Sodium [Na] deficiency  Excludes1: syndrome of inappropriate secretion of antidiuretic hormone (E22.2)

E87.2 Acidosis Acidosis NOS Lactic acidosis Metabolic acidosis Respiratory acidosis Excludes1: diabetic acidosis - see categories E10-E13 with ketoacidosis

E87.3 Alkalosis Alkalosis NOS Metabolic alkalosis Respiratory alkalosis

E87.4 Mixed disorder of acid-base balance

E87.5 Hyperkalemia Potassium [K] excess Potassium [K] overload

E87.6 Hypokalemia Potassium [K] deficiency

E87.7 Fluid overload Excludes1: edema NOS (R60.-)

E87.8 Other disorders of electrolyte and fluid balance, not elsewhere classified Electrolyte imbalance NOS Hyperchloremia Hypochloremia

E88 Other and unspecified metabolic disorders Use additional codes for associated conditions  Excludes1: histiocytosis X (chronic) (C96.6)

E88.0 Disorders of plasma-protein metabolism, not elsewhere classified

Excludes1: disorder of lipoprotein metabolism (E78.-) monoclonal gammopathy (of undetermined significance) (D47.2)polyclonal hypergammaglobulinemia (D89.0) Waldenström macroglobulinemia (C88.0)

E88.01 Alpha-1-antitrypsin deficiency AAT deficiency

E88.09 Other disorders of plasma-protein metabolism, not elsewhere classified Bisalbuminemia

E88.1 Lipodystrophy, not elsewhere classified Lipodystrophy NOS Excludes1: Whipple's disease (K90.81)

E88.2 Lipomatosis, not elsewhere classified Lipomatosis NOS Lipomatosis (Check) dolorosa [Dercum]

E88.3 Tumor lysis syndrome  Tumor lysis syndrome (spontaneous) Tumor lysis syndrome following antineoplastic drug chemotherapy Code first (T45.1-) to identify drug, if drug induced

E88.4 Mitochondrial metabolism disorders

Excludes1: disorders of pyruvate metabolism (E74.4) Kearns-Sayre syndrome (H49.81) Leber's disease (H47.22) Leigh's encephalopathy (G31.82) Mitochondrial myopathy, NEC (G71.3) Reye's syndrome (G93.7)

E88.40 Mitochondrial metabolism disorder, unspecified
E88.41 MELAS syndrome Mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes
E88.42 MERRF syndrome Myoclonic epilepsy associated with ragged-red fibers Code also: myoclonic epilepsy (G40.3-)
E88.49 Other mitochondrial metabolism disorders
E88.8 Other specified metabolic disorders
E88.81 Metabolic syndrome Dysmetabolic syndrome X
E88.89 Other specified metabolic disorders Launois-Bensaude adenolipomatosis
E88.9 Metabolic disorder, unspecified

Clinical records and Fiscal records Guidelines


The following table contains general guidelines for clinical documentation that must be maintained by all providers except nursing facilities. Clinical records other than those listed may also be needed to clearly document all information pertinent to services that are rendered to beneficiaries. All providers must refer to their specific coverage policy in this manual for additional documentation requirements. The clinical record must be sufficiently detailed to allow reconstruction of what transpired for each service billed. All documentation for services provided must be signed and dated by the rendering health care professional.

For services that are time-specific according to the procedure code billed, providers must indicate in the medical record the actual begin time and end time of the particular service. For example, some Physical Medicine procedure codes specify per 15 minutes. If the procedure started at 3:00 p.m. and ended at 3:15 p.m., the begin time and end time must be recorded in the medical record.

The medical record must indicate the specific findings or results of diagnostic or therapeutic procedures. If an abbreviation, symbol, or other mark is used, it must be standard, widely accepted health care terminology. Symbols, marks, etc. unique to that provider must not be used.


** When a test is performed, at a minimum, the test value for that beneficiary for that test must be noted. Additionally, the normal range of values for the testing methodology should be annotated in the record.

** When an x-ray is taken, the results or findings must be indicated. For example, a chest x-ray may indicate "no pulmonary edema present" or "no consolidation."

** When a physical examination is performed, pertinent results or readings must appear.

** If blood pressure is taken, the actual reading must appear.

** If heart, lungs, eyes, etc. are checked, the results or findings must be detailed.

** Medical/surgical procedures performed must be sufficiently documented to allow another professional to reconstruct what transpired (e.g., "I-D" is not sufficient documentation).

** When a complete physical exam is rendered, the level of service must be fully documented.

** If private duty nursing is provided, the care provided during each hour must be fully detailed.

Hospitals must retain any clinical information required to comply with 42 CFR 482.24. A nursing facility must retain any clinical information required to comply with 42 CFR 483.75 and the plan of care must comply with 42 CFR 483.20(d). These regulations are available from MDHHS or Centers for Medicare & Medicaid Services (CMS). (Hospitals and nursing facilities should refer to the Reimbursement Appendix of their chapters in this manual for additional record keeping requirements.)


The following fiscal records must be maintained:

** Copies of Remittance Advices (RA);

** PA requests and approvals for services and supplies (including managed care authorizations);

** Verification of medical necessity and the provider's usual and customary charge for the noncovered service;

** Record of third-party payments; and

** Copies of purchase invoices for items offered or supplied to the beneficiary.


Providers must maintain, in English and in a legible manner, written or electronic records necessary to fully disclose and document the extent of services provided to beneficiaries. Necessary records include fiscal and clinical records as discussed below. Appointment books and any logs are also considered a necessary record if the provider renders a service that is time-specific according to the procedure code billed. Examples of services that are time-specific are psychological testing (per hour), medical psychotherapy (20-30 minutes), and vision orthoptic treatment (30 minutes). The records are to be retained for a period of not less than seven years from the DOS, regardless of change in ownership or termination of participation in Medicaid for any reason. This requirement is also extended to any subcontracted provider with which the provider has a business relationship.


Providers arranging or rendering services upon the order, prescription or referral of another provider (e.g., physician) must maintain that order, prescription and/or referral for a period of seven years.


Providers must retain the following beneficiary identification information in their records:

** Name

** Medicaid ID number

** Medical record number

** Address, including zip code

** Birth date

** Telephone number, if available

** Any private health insurance information for the beneficiary, if available


Providers are required to permit MDHHS personnel, or authorized agents, access to all information concerning any services that may be covered by Medicaid. This access does not require an authorization from the beneficiary because the purpose for the disclosure is permitted under the HIPAA Privacy rule. Health plans contracting with the MDHHS must be permitted access to all information relating to services reimbursed by the health plan.

Providers must, upon request from authorized agents of the state or federal government, make available for examination and photocopying all medical records, quality assurance documents, financial records, administrative records, and other documents and records that must be maintained. (Failure to make requested records available for examination and duplication and/or extraction through the method determined by authorized agents of the state or federal government may result in the provider's
suspension and/or termination from Medicaid.) Records may only be released to other individuals if they have a release signed by the beneficiary authorizing access to his records or if the disclosure is for a permitted purpose under all applicable confidentiality laws.


MDHHS complies with HIPAA Privacy requirements and recognizes the concern for the confidential relationship between the provider and the beneficiary and protects this relationship using the minimum amount of information necessary for purposes directly related to the administration of Medicaid. All records are of a confidential nature and should not be released, other than to a beneficiary or his representative, unless the provider has a signed release from the beneficiary or the disclosure is for a permitted purpose under all applicable confidentiality laws (refer to the Availability of Records subsection of this chapter for additional information). Providers are bound to all HIPAA privacy and security requirements as federally mandated.

If the provider receives a court order, a subpoena, beneficiary request, or other authorized request for medical bills, payment, or claims adjudication information, the information should be released. At the same time, copies of the court order, subpoena, beneficiary request, other authorized request, and any additional information should be faxed to the MDHHS TPL Section. (Refer to the Directory Appendix for contact information.)

If there is a reason to suspect a duplicate payment has been or will be made, but the payment is not assigned, the provider should contact the TPL Section. TPL will make the necessary arrangements to collect the duplicate payment from the third-party source.

If the provider questions the appropriateness of releasing beneficiary records, he is encouraged to seek legal counsel before doing so.

ICD 10 code for dysphagia - R13

Diseases of the blood and blood-forming organs and certain disorders involving the forming organs and certain disorders involving the forming organs and certain disorders involving the immune mechanism (D50- immune mechanism (D50-D89)

Iron deficiency anemia (D50)

Iron deficiency anemia secondary to blood loss (chronic) (D50.0)

Sideropenic dysphagia (D50.1)

Other iron deficiency anemias (D50.8)

Iron deficiency anemia, unspecified (D50.9)

Vitamin B12 deficiency anemia (D51)

Vitamin B12 deficiency anemia due to intrinsic factor deficiency (D51.0)

Vitamin B12 deficiency anemia due to selective vitamin B12 malabsorption with proteinuria (D51.1)

Transcobalamin II deficiency (D51.2)

Other dietary vitamin B12 deficiency anemia (D51.3)

Other vitamin B12 deficiency anemias (D51.8)

Vitamin B12 deficiency anemia, unspecified (D51.9)

Folate deficiency anemia (D52)

Dietary folate deficiency anemia (D52.0)

Nausea and vomiting (R11)

Heartburn (R12)

Dysphagia (R13)

Flatulence and related conditions (R14)

Fecal incontinence (R15)

Drug-induced folate deficiency anemia (D52.1)

Other folate deficiency anemias (D52.8)

Folate deficiency anemia, unspecified (D52.9)

Other nutritional anemias (D53)

Protein deficiency anemia (D53.0)

Other megaloblastic anemias, not elsewhere classified (D53.1)

Scorbutic anemia (D53.2)

Other specified nutritional anemias (D53.8)

Nutritional anemia, unspecified (D53.9)

Iron deficiency

Originally described in the context of sideropenic dysphagia, it is an important cause of epithelial atrophy. The association of iron deficiency with oropharyngeal squamous cell carcinomas has been observed since the mid-thirties of the 20th century {21}. However, a significant decrease of cases with hypopharyngeal cancers and iron deficiency was noted in Sweden in the seventies {1433}. Few cases of oral cancer and iron deficiency have been published in the last 20 years.

Mucoepidermoid carcinoma

This most common malignant salivary gland tumour involves minor glands, and accounts for 9.5-23% of all minor gland tumours {669,704,2711}. About half of the cases arise in the palate and other common sites include the buccal mucosa, lips, floor of oral cavity and retromolar pad. They appear to be much more frequent in the lower lip than the upper lip {1871}. The tumour is often asymptomatic and detected during a routine dental examination.Many appear as bluish, domed swellings that resemble mucoceles or haemangiomas. Less commonly, the surface appears granular or papillary. Tumours of the base of tongue or oropharynx may cause dysphagia and sublingual tumours can lead to ankyloglossia and dysphonia. High-grade tumours are uncommon but can result in ulceration, loosening of teeth, paraesthesia or anaesthesia. Mucoepidermoid carcinoma is the most common salivary gland tumour to develop in a central location within the bone of the mandible or, less frequently, the maxilla {280}. The microscopical features of minor gland mucoepidermoid carcinomas are the same as those seen in the major glands.

Clinical features

Patients with NHL of the lip, buccal mucosa, gingiva, floor of mouth, tongue or palate usually present with ulcer, swelling, discoloration, pain, paraesthesia, anaesthesia, or loose teeth. Those with NHL of the Waldeyer ring (tonsils) or oropharynx usually present with a sensation of fullness of the throat, sore throat, dysphagia, or snoring. The high-grade tumours often show rapid growth. Systemic symptoms such as fever and night sweat are uncommon {201}.

Clinical examination reveals solitary or multiple lesions, in the form of an exophytic mass, ulcer or localized swelling. Some cases may mimic inflammatoryconditions, such as periodontitis.

Tonsillar lymphoma usually manifests as asymmetric tonsil enlargement, although the disease can be bilateral in up to 9% of cases {2250}. The regional lymph nodes can be enlarged as a result of lymphoma involvement or reactive changes secondary to ulceration.

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