2025 CPT code 40816
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Oral Cavity Surgery Feed
Excision of a lesion from the mucosa and submucosa of the mouth vestibule, involving complex repair with underlying muscle excision.
Modifiers may apply depending on the specifics of the procedure and additional services rendered (e.g., 22 for increased procedural services, 51 for multiple procedures, 59 for distinct procedural services, etc.). Consult the official CPT manual for the latest modifier guidelines.
Medical necessity is established when the lesion is causing functional impairment, significant discomfort, or represents a potential malignancy.Appropriate clinical justification and rationale must support the excision of the lesion and the complexity of the repair.
The provider prepares the patient, administers anesthesia, makes incisions using a scalpel or electrocautery, removes the lesion and margins, excises underlying muscle, and closes the incision with sutures. The complexity of the repair is determined by the lesion's depth and may involve additional techniques like tissue rearrangement or flaps.
In simple words: The doctor removes a damaged or diseased area of tissue in the inner lining of the mouth (near the lips and cheeks). This may involve removing some underlying muscle tissue as well. The doctor then closes the area with stitches.
This procedure involves the excision of a lesion affecting the mucosa and submucosa of the mouth's vestibule.The excision is complex, requiring removal of underlying muscle tissue.The surgical wound is closed with sutures. The depth of excision and closure technique depend on the lesion's depth and may involve more complex suturing, tissue rearrangement, or the use of tissue flaps.
Example 1: A patient presents with a large, deep mucocele in the lower lip vestibule. The provider performs a complex excision, removing the mucocele, underlying muscle tissue, and carefully closes the wound with layered sutures., A patient with a recurrent, deep ulcer in the buccal vestibule requires excision of the ulcer and underlying muscle tissue due to its depth and recurrence. The surgeon utilizes a tissue flap to ensure optimal wound closure., A patient presents with a suspicious lesion in the upper lip vestibule which, upon biopsy during the excision procedure, is confirmed as malignant. Due to the depth and nature of the lesion the provider excises more tissue and performs a complex closure with tissue rearrangement to ensure sufficient margins are taken.
Detailed operative notes describing the size, location, and depth of the lesion, the method of excision (scalpel or electrocautery), tissue removed, and the type of wound closure.Pre-operative photographs may be helpful.Post-operative instructions and follow-up plans should also be documented. Pathological report confirming diagnosis of the excised lesion.Imaging (if any) that supports the diagnosis or planning of the surgical procedure.
** The complexity of this procedure is judged based on several factors including the depth of the lesion, the need for tissue rearrangement or flaps, the extent of underlying muscle excision, and the complexity of the closure.Accurate documentation is crucial for appropriate reimbursement.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier is not usually applicable to this code as it represents a single comprehensive surgical procedure.
- Specialties:Oral and Maxillofacial Surgery, Plastic Surgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)