2025 CPT code 40490
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
Biopsy of lip.
Modifiers may be applicable. Refer to the provided list of modifiers and their descriptions for specific use cases.
Medical necessity is established by the presence of a suspicious lip lesion, symptoms suggestive of Sjögren's syndrome, or other conditions requiring histopathological diagnosis.
The physician is responsible for preparing the patient, administering anesthesia, incising the lip, removing the lesion with appropriate margins, controlling bleeding, and closing the incision.
In simple words: The doctor takes a small tissue sample from your lip to check for any problems. This is done by numbing the area, making a small cut, removing a bit of tissue, and then closing the cut.
This code describes a procedure where a biopsy of the lip is performed.The physician incises the lip and takes a sample of the lesion for diagnostic purposes.This typically involves making an elliptical incision, dissecting the lesion with scissors, removing it, and controlling bleeding with chemocautery or electrocautery.
Example 1: A patient presents with a suspicious lesion on their lip that has not resolved after two weeks of conservative management. A biopsy is performed to rule out malignancy., A patient with suspected Sjögren's syndrome undergoes a lip biopsy of the minor salivary glands to assess the degree of glandular destruction and guide therapy., A child with a persistent papular lesion on their lip undergoes a biopsy under sedation to determine the cause and guide treatment.
Documentation should include the location and description of the lesion, the method of biopsy, the size and depth of the incision, the method of hemostasis, and any complications.For Sjögren's syndrome diagnosis, include related symptoms and other diagnostic tests.
- Revenue Code: P6C - MINOR PROCEDURES - OTHER (MEDICARE FEE SCHEDULE)
- Specialties:Oral Surgery, Dermatology, Otolaryngology, Plastic Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center