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The CPT® Code 40805 refers to the procedure for the removal of an embedded foreign body located in the vestibule of the mouth, classified as a complicated case. This procedure is necessary when a foreign object has become lodged in the oral vestibule, which is the space between the gums and the inner lining of the lips and cheeks. The term "complicated" indicates that the foreign body is not easily accessible and may require more intricate surgical techniques to extract. The procedure involves making a straight or elliptical incision to access the area, followed by careful separation of the mucosa and submucosa to identify the foreign body. The use of specialized instruments, such as a hemostat or grasping forceps, is essential for the effective removal of the foreign object. Depending on the situation, the incision may either be closed after the removal or left open to heal naturally through secondary intention, which is a process where the wound heals from the bottom up without surgical closure. This code is specifically designated for cases where the foreign body is deeply embedded and poses challenges in localization, necessitating potential dissection of the underlying tissues to ensure complete removal.
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The procedure associated with CPT® Code 40805 is indicated in specific scenarios where a foreign body is embedded in the vestibule of the mouth. The following conditions warrant this procedure:
The procedure for CPT® Code 40805 involves several critical steps to ensure the safe and effective removal of the embedded foreign body:
Post-procedure care for patients undergoing the removal of an embedded foreign body using CPT® Code 40805 includes monitoring for any signs of infection or complications at the incision site. Patients may be advised to maintain good oral hygiene to promote healing and prevent infection. If the incision is left open, the physician may provide specific instructions on how to care for the wound as it heals naturally. Follow-up appointments may be necessary to assess the healing process and ensure that no residual foreign material remains. Additionally, patients should be informed about potential symptoms that may indicate complications, such as increased pain, swelling, or discharge from the incision site, and advised to seek medical attention if these occur.
| Short Descr | REMOVAL FOREIGN BODY MOUTH | Medium Descr | RMVL EMBEDDED FB VESTIBULE MOUTH COMP | Long Descr | Removal of embedded foreign body, vestibule of mouth; complicated | 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 | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 2 | 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). | 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 | 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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