2025 CPT code 40831

Repair of a laceration of the vestibule of the mouth, exceeding 2.5 cm in length or requiring complex closure.

Refer to CPT guidelines for surgery and the specific guidelines for the vestibule of the mouth to ensure accurate coding.

Modifiers may be applicable to this code. Refer to current CPT guidelines for appropriate modifier usage.

Medical necessity for this procedure is established by the presence of a laceration of the oral vestibule that requires closure to control bleeding, prevent infection, and restore normal oral function. The size or complexity of the laceration justifies the use of this specific code.

The physician is responsible for preparing the patient, providing appropriate anesthesia, and performing the closure of the laceration.This includes achieving hemostasis and ensuring the wound is closed in a manner that promotes optimal healing and restoration of function.

IMPORTANT For lacerations of the vestibule of the mouth less than 2.5 cm and amenable to simple closure, use code 40830.

In simple words: This procedure fixes a cut or tear inside the mouth, between the cheek and teeth, that is either long or complicated. The doctor numbs the area and closes the cut using stitches, special tape, or medical glue.

This code describes the repair of a laceration in the vestibule of the mouth (the space between the cheeks and teeth) when the laceration is longer than 2.5 cm or requires a complex closure due to its nature.The procedure involves preparing the patient, administering anesthesia, and closing the laceration using appropriate methods like sutures, tapes, or adhesives. The goal is to achieve hemostasis and facilitate proper healing to restore normal oral function.

Example 1: A patient presents with a 2.8 cm laceration in the vestibule of the mouth following a bicycle accident. The laceration is cleaned and closed with sutures., A child falls and sustains a complex laceration to the buccal vestibule, requiring layered closure due to involvement of multiple tissue planes., An adult with a deep laceration, over 2.5 cm, to the vestibule of the mouth caused by a sharp object requires complex closure to control bleeding and promote healing.

Documentation should include the location, size, and complexity of the laceration, the method of closure (sutures, staples, adhesive), the type of anesthesia used, and any complications encountered.It's also important to document the cause of the injury.

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