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The CPT® Code 40804 refers to the procedure for the removal of an embedded foreign body located in the vestibule of the mouth. This procedure is classified as a simple removal, which involves making a straight or elliptical incision in the oral mucosa. The mucosa and submucosa are carefully separated to expose the foreign body, allowing for its identification. Once located, a hemostat or grasping forceps is utilized to extract the foreign body from the tissue. After the removal, the incision may either be closed with sutures or left open to heal naturally through secondary intention. It is important to note that this code is specifically designated for cases that do not involve complications. In instances where the foreign body is deeply embedded and requires more complex dissection of underlying tissues, CPT® Code 40805 should be used instead, indicating a more complicated procedure. This distinction is crucial for accurate coding and billing purposes, ensuring that the complexity of the procedure is appropriately reflected in the coding documentation.
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The procedure associated with CPT® Code 40804 is indicated for the removal of embedded foreign bodies in the vestibule of the mouth. This may include instances where patients present with symptoms such as:
The procedure for the removal of an embedded foreign body in the vestibule of the mouth involves several key steps:
Post-procedure care following the removal of an embedded foreign body includes monitoring the surgical site for signs of infection, such as increased redness, swelling, or discharge. Patients are typically advised to maintain good oral hygiene to promote healing and prevent complications. If the incision was closed, follow-up appointments may be necessary to assess the healing process and remove any sutures if applicable. Patients should also be instructed to avoid irritating the area with hard or sharp foods until fully healed. Any unusual symptoms or concerns should prompt the patient to contact their healthcare provider for further evaluation.
| Short Descr | REMOVAL FOREIGN BODY MOUTH | Medium Descr | RMVL EMBEDDED FB VESTIBULE MOUTH SMPL | Long Descr | Removal of embedded foreign body, vestibule of mouth; simple | Status Code | Active Code | Global Days | 010 - Minor Procedure | 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) | 0 - 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 | STV-Packaged Codes | ASC Payment Indicator | Packaged service/item; no separate payment made. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 229 - Nonoperative removal of foreign body |
| 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2011-01-01 | Changed | Short description changed. |
| Pre-1990 | Added | Code added. |
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