© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 40843 refers to a bilateral vestibuloplasty, which is a surgical intervention aimed at modifying the vestibule of the mouth. The vestibule, also known as the buccal or oral cavity, encompasses the mucosal and submucosal tissues of the lips and cheeks, while excluding the dentoalveolar structures. The primary objective of vestibuloplasty is to restore the height of the alveolar ridge, which is the bony ridge in the upper and lower jaws that contains the sockets for teeth. This procedure is particularly beneficial for patients with congenital conditions such as cleft lip and/or palate, as well as other facial deformities, where the soft tissue and underlying bone may require reshaping to achieve both aesthetic and functional improvements. In addition, vestibuloplasty can be performed on edentulous patients who have a shallow vestibular sulcus, with the goal of deepening the vestibule to enhance the fit of dentures or dental implants. The surgical technique involves making an incision in the mucosa located in the sulcus between the lip or cheek and the alveolar ridge, allowing for the separation of connective tissue and muscle attachments. Following the incision, the buccal or labial tissue is repositioned and sutured in its new location, or a graft may be utilized to cover the incision site. This procedure is categorized as bilateral when it involves both sides of the mouth, distinguishing it from unilateral vestibuloplasty, which is coded separately. Overall, vestibuloplasty is a critical procedure in oral and maxillofacial surgery that facilitates improved oral function and aesthetics for various patient populations.
© Copyright 2025 Coding Ahead. All rights reserved.
The indications for performing a bilateral vestibuloplasty (CPT® Code 40843) include the following:
The procedure for bilateral vestibuloplasty involves several key steps, which are detailed as follows:
Post-procedure care following a bilateral vestibuloplasty includes monitoring for any signs of complications, such as infection or excessive bleeding. Patients are typically advised to follow specific oral hygiene practices to maintain cleanliness in the surgical area. Additionally, a post-surgical stent or denture may be placed over the alveolar ridge and secured with screws to facilitate adherence of the overlying tissue to the periosteum. This stent or denture is generally removed approximately two weeks after the procedure, allowing for adequate healing and stabilization of the tissues.
| Short Descr | RECONSTRUCTION OF MOUTH | Medium Descr | VESTIBULOPLASTY POSTERIOR BILATERAL | Long Descr | Vestibuloplasty; posterior, bilateral | Status Code | Restricted Coverage | 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) | 2 - 150% payment adjustment does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply 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 | 1 | 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). | 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.) |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.