© Copyright 2025 American Medical Association. All rights reserved.
The CPT® Code 40510 refers to the excision of the lip through a transverse wedge excision technique, which is followed by primary closure of the surgical site. This procedure is typically performed to remove a lesion, scar, or other defect located on the lip. The process begins with the physician marking the planned incision lines using a surgical marking pen, ensuring that the incision encompasses a margin of healthy tissue surrounding the lesion to promote optimal healing and reduce the risk of recurrence. Prior to making the incision, local anesthetic, often combined with epinephrine, is injected into the lip to minimize discomfort and control bleeding during the procedure. The transverse wedge excision involves making incisions that are perpendicular to the lip's surface on either side of the lesion, extending through the vermilion, which is the pink part of the lip. The incisions converge at the white part of the lip, allowing for the removal of a wedge-shaped section of tissue. After excising the tissue, the edges of the wound are meticulously reapproximated in layers, with particular attention given to aligning the vermilion border to ensure a cosmetically pleasing result. This procedure is essential for addressing various lip lesions while maintaining the functional and aesthetic integrity of the lip structure.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 40510 is indicated for the excision of lesions, scars, or other defects of the lip. The following conditions may warrant this surgical intervention:
The procedure for CPT® Code 40510 involves several key steps that ensure the effective excision of the lip lesion while maintaining the integrity of the surrounding tissue:
Post-procedure care for patients undergoing the excision of the lip includes monitoring for any signs of infection, managing pain, and ensuring proper wound healing. Patients are typically advised to avoid strenuous activities and refrain from manipulating the surgical site to promote healing. Follow-up appointments may be scheduled to assess the healing process and to remove any sutures if necessary. Additionally, patients should be informed about potential changes in sensation or appearance of the lip as part of the recovery process.
| Short Descr | PARTIAL EXCISION OF LIP | Medium Descr | EXC LIP TRANSVRS WEDGE EXC W/PRIM CLSR | Long Descr | Excision of lip; transverse wedge excision with primary closure | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 2 | CCS Clinical Classification | 33 - Other OR therapeutic procedures on nose, mouth and pharynx |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |