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The procedure described by CPT® Code 40814 involves the excision of a lesion located in the mucosa and submucosa of the vestibule of the mouth, which is the area between the lips and the gums. This area is also known as the buccal cavity and includes the soft tissues of the lips and cheeks, but it does not encompass the underlying dentoalveolar structures. During the procedure, a local anesthetic is administered to ensure patient comfort. The surgeon identifies a margin of healthy tissue surrounding the lesion and makes an incision through the mucosa and submucosa. This incision is carefully crafted to encircle the lesion, allowing for complete excision of the abnormal tissue. After the lesion is removed, the surgical site is thoroughly inspected to confirm that all affected tissue has been excised. The excised lesion is then sent to a laboratory for histologic evaluation, which is a separate reportable service. In cases where the surgical wound is left open to heal naturally, CPT® Code 40810 is applicable. If the wound is closed using a simple single-layer suture technique, CPT® Code 40812 should be used. However, when a complex repair is necessary, as in the case of CPT® Code 40814, the procedure involves extensive undermining of the surrounding tissues to reduce tension on the wound. This is achieved using surgical instruments such as scissors or a scalpel. Hemostasis, or control of bleeding, is managed through chemical means or electrocautery. The deeper layers of the wound are then closed with absorbable sutures, ensuring that the knots are buried to minimize irritation. In some instances, stents or retention sutures may be employed to support the closure. The final step involves closing the superficial layer of the wound, with careful attention to aligning and everting the wound edges to promote optimal healing. It is important to note that if the excision extends beyond the mucosa and submucosa to include muscle, CPT® Code 40816 would be the appropriate code to use, indicating a more complex surgical intervention.
© Copyright 2025 Coding Ahead. All rights reserved.
The excision of lesions in the vestibule of the mouth, as described by CPT® Code 40814, is indicated for various conditions that may affect the mucosa and submucosa. These indications include:
The procedure for excising a lesion of the mucosa and submucosa in the vestibule of the mouth involves several critical steps:
After the excision and closure of the wound, post-procedure care is essential for promoting healing and preventing complications. Patients are typically advised to follow specific instructions regarding oral hygiene and dietary modifications to avoid irritation of the surgical site. Pain management may be necessary, and patients may be prescribed analgesics to manage discomfort. Follow-up appointments are important to monitor the healing process and to review the results of the histologic evaluation. Any signs of infection, such as increased swelling, redness, or discharge, should be reported to the healthcare provider promptly. Additionally, patients should be informed about the signs of complications that may require further medical attention.
| Short Descr | EXCISE/REPAIR MOUTH LESION | Medium Descr | EXC LESION MUCOSA & SBMCSL VESTIBULE CPLX RPR | Long Descr | Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair | 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 | 4 | CCS Clinical Classification | 33 - Other OR therapeutic procedures on nose, mouth and pharynx |
| 47 | Anesthesia by surgeon: regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (this does not include local anesthesia.) note: modifier 47 would not be used as a modifier for the anesthesia procedures. | 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. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 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.) | AG | Primary physician | 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 | GW | Service not related to the hospice patient's terminal condition | 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) | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| Pre-1990 | Added | Code added. |
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