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The procedure described by CPT® Code 40831 pertains to the closure of a laceration located in the vestibule of the mouth that exceeds 2.5 cm in length or is classified as complex. This procedure is essential for restoring the integrity of the oral mucosa and surrounding tissues following an injury. The process begins with the cleansing of the wound to prevent infection, followed by the administration of a local anesthetic to ensure patient comfort during the procedure. A thorough inspection of the wound is conducted to assess its depth and involvement of various tissue layers, including the mucosa, submucosa, and deeper connective tissues. If necessary, debridement is performed to remove any devitalized tissue, which is crucial for promoting optimal healing. The closure technique involves a layered approach, utilizing sutures, staples, or tissue adhesive to secure the tissues effectively. To minimize tension on the wound, the tissues may be undermined using surgical instruments such as scissors or a scalpel. Control of bleeding is achieved through chemical means or electrocautery, ensuring a clean surgical field. The deepest layers of the wound are closed with absorbable sutures, with the knots buried to reduce irritation and promote healing. The superficial layer is then meticulously closed, ensuring that the edges of the wound are aligned and everted, which is vital for preventing a depressed scar. It is important to note that for lacerations measuring 2.5 cm or less, CPT® Code 40830 should be utilized, while CPT® Code 40831 is specifically designated for those that are longer or require complex repair, which may involve extensive debridement and undermining of tissue. In some cases, stents or retention sutures may be necessary to achieve proper closure of the wound.
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The procedure associated with CPT® Code 40831 is indicated for the closure of lacerations in the vestibule of the mouth that are either over 2.5 cm in length or classified as complex. The following conditions may warrant this procedure:
The procedure for CPT® Code 40831 involves several critical steps to ensure effective closure of the laceration:
After the procedure, appropriate post-operative care is essential for optimal recovery. Patients should be advised on wound care, including keeping the area clean and dry, and monitoring for signs of infection such as increased redness, swelling, or discharge. Follow-up appointments may be necessary to assess healing and remove any non-absorbable sutures if used. Patients should also be informed about potential complications and the importance of adhering to post-operative instructions to ensure proper healing and minimize the risk of scarring.
| Short Descr | REPAIR MOUTH LACERATION | Medium Descr | CLOSURE LACERATION VESTIBULE MOUTH > 2.5 CM/CPL | Long Descr | Closure of laceration, vestibule of mouth; over 2.5 cm or complex | 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 | 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 | 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. | 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) | 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). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 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.) | 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 | GJ | "opt out" physician or practitioner emergency or urgent service | JG | Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes | 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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