2025 CPT code 40810
(Active) Effective Date: N/A Revision Date: N/A Surgery - Excision and Destruction Procedures on the Vestibule of Mouth Digestive System Feed
Excision of a lesion from the mouth's vestibule mucosa and submucosa without wound repair.
Modifiers may be applicable depending on the circumstances of the procedure.Consult the CPT manual and payer guidelines for appropriate modifier usage.
Medical necessity for 40810 is established by the presence of a lesion in the vestibule of the mouth that requires excision for diagnostic or therapeutic purposes.The size, location, and characteristics of the lesion, along with the patient's symptoms, justify the need for the procedure.For example, a rapidly growing lesion or one that is causing significant discomfort or functional impairment may warrant excision.
The physician is responsible for pre-operative preparation, administering anesthesia (if necessary), excising the lesion, and ensuring proper hemostasis.No wound closure is included in this procedure.
In simple words: The doctor cuts out a damaged or diseased area of tissue in the inside of the mouth, between the lips/cheeks and teeth/gums.The cut is not stitched closed.
This CPT code, 40810, describes the surgical excision of a lesion (damaged or diseased tissue) located in the mucosa and submucosa of the vestibule of the mouth.The vestibule is the area between the lips/cheeks and the teeth and gums. The procedure involves removing the lesion and its margins without subsequent repair of the surgical wound.The lesion may be excised using a scalpel or electrocautery.
Example 1: A patient presents with a mucocele on the lower lip's vestibular mucosa. The physician excises the lesion without repair., A patient has a small, benign fibroma on the buccal mucosa near the molar region.The physician excises the lesion without repair., A patient presents with a suspicious lesion on the vestibular mucosa. The physician excises the lesion for biopsy, and the pathology report will determine further treatment.
Detailed operative notes describing the location, size, and nature of the lesion.A pathology report confirming the diagnosis is crucial.Preoperative and postoperative photographs may also be beneficial.Documentation of the method of hemostasis and the absence of any wound repair should be clearly stated.
** Accurate documentation of the lesion's characteristics, size, and location is vital for proper coding and reimbursement.If a repair is performed, a different CPT code (40812 or 40814) must be selected.
- Revenue Code: P6C (Medicare Fee Schedule: MINOR PROCEDURES - OTHER)
- RVU: This information is not available in the provided source.Consult the current Medicare Physician Fee Schedule for RVU values.
- Global Days: The provided source does not specify global days.This should be determined based on local payer guidelines.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier is not usually applicable to this code as it represents a complete procedure, excluding wound repair.
- Fee Schedule: This information is not provided in the source.Consult historical fee schedules for relevant data.
- Specialties:Oral and Maxillofacial Surgery, Dentistry
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center