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The procedure described by CPT® Code 40816 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 cheeks, excluding the teeth and gums. This procedure is classified as complex due to the involvement of underlying muscle tissue in addition to the mucosal layers. Initially, the lesion is identified, and a local anesthetic is administered to ensure patient comfort during the procedure. A careful incision is made through the mucosa and submucosa, encircling the lesion to ensure complete removal. The surgeon inspects the surgical site to confirm that all abnormal tissue has been excised, and the removed tissue is sent for histologic evaluation to assess its nature. 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, which involves extensive undermining of the tissues to reduce tension on the wound, CPT® Code 40816 is appropriate. This complex repair may involve techniques such as chemical or electrocautery for bleeding control, the use of absorbable sutures for deeper layers, and ensuring proper alignment and eversion of the wound edges in the superficial layer. It is important to note that CPT® Code 40814 is used when the excision is limited to mucosa and submucosa without muscle involvement, requiring a complex repair. Thus, CPT® Code 40816 is specifically designated for cases where both muscle and mucosal layers are excised and a complex repair is performed.
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The excision of lesions in the vestibule of the mouth is typically indicated for various conditions that may affect the mucosa and submucosa, particularly when these lesions are suspected to be abnormal or potentially malignant. The following are common indications for performing this procedure:
The procedure for excising a lesion of the mucosa and submucosa in the vestibule of the mouth involves several detailed steps:
After the excision and closure of the surgical site, post-procedure care is essential for optimal recovery. Patients are typically advised to follow specific instructions regarding wound care, which may include keeping the area clean and dry, avoiding certain foods that could irritate the site, and monitoring for signs of infection such as increased redness, swelling, or discharge. Follow-up appointments may be scheduled to assess healing and discuss the results of the histologic evaluation of the excised tissue. Patients should also be informed about potential complications, such as bleeding or delayed healing, and when to seek medical attention if they experience any concerning symptoms.
| Short Descr | EXCISION OF MOUTH LESION | Medium Descr | EXC LESION MUCOSA&SBMCSL VESTIBULE CPLX EXC MUSC | Long Descr | Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying muscle | 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 |
| 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). | 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. | 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. | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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) | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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