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The procedure described by CPT® Code 40830 pertains to the closure of a laceration located in the vestibule of the mouth, specifically when the length of the laceration is 2.5 cm or less. This procedure involves several critical steps to ensure proper healing and aesthetic outcomes. Initially, the wound is thoroughly cleansed to prevent infection, and a local anesthetic is administered to minimize discomfort during the procedure. The healthcare provider inspects the wound to assess its depth and extent, confirming that it involves the mucosa, submucosa, and deeper connective tissues. If necessary, debridement is performed to remove any devitalized tissue, which is essential for promoting healing. Following this, a layered closure technique is employed, which may involve the use of sutures, staples, or tissue adhesive. To reduce tension on the wound and facilitate optimal healing, the tissues are undermined using surgical instruments such as scissors or a scalpel. Control of any bleeding is achieved through chemical means or electrocautery. The closure process begins with the deepest layers of tissue being secured with absorbable sutures, ensuring that the knots are buried to minimize irritation. The superficial layer is then closed with careful attention to aligning and everting the wound edges, which is crucial for preventing a depressed scar. It is important to note that for lacerations exceeding 2.5 cm or those requiring complex repair, CPT® Code 40831 should be utilized, as complex repairs may involve extensive debridement and the use of stents or retention sutures to secure the wound effectively.
© Copyright 2025 Coding Ahead. All rights reserved.
The closure of a laceration in the vestibule of the mouth, as described by CPT® Code 40830, is indicated for the following conditions:
The procedure for the closure of a laceration in the vestibule of the mouth involves several detailed steps:
After the procedure, the patient may be monitored for any immediate complications, such as excessive bleeding or signs of infection. Instructions for post-procedure care typically include keeping the area clean and dry, avoiding trauma to the site, and following up with the healthcare provider as needed. Patients may also be advised on pain management strategies and signs of infection to watch for during the recovery period. The expected recovery time will vary based on individual healing processes, but proper care is essential to ensure optimal healing and minimize scarring.
| Short Descr | REPAIR MOUTH LACERATION | Medium Descr | CLOSURE LACERATION VESTIBULE MOUTH 2.5 CM/< | Long Descr | Closure of laceration, vestibule of mouth; 2.5 cm or less | 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 OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 2 | CCS Clinical Classification | 32 - Other non-OR therapeutic procedures on nose, mouth and pharynx |
| 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. | RT | Right side (used to identify procedures performed on the right side of the body) | LT | Left side (used to identify procedures performed on the left side of the body) | 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. | 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). | 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.) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | 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 | 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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| Pre-1990 | Added | Code added. |
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