© Copyright 2025 American Medical Association. All rights reserved.
The procedure known as vestibuloplasty, specifically coded as CPT® 40844, involves surgical intervention aimed at the vestibule of the mouth, which encompasses the mucosal and submucosal tissues of the lips and cheeks, while excluding the dentoalveolar structures. This surgical technique is primarily performed 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. In cases where patients present with conditions such as cleft lip and/or palate or other facial deformities, vestibuloplasty may be necessary to remodel the vestibular soft tissue and the underlying alveolar ridge bone. This remodeling is crucial for achieving both cosmetic and functional outcomes. Additionally, vestibuloplasty can be beneficial for edentulous patients who have a shallow vestibular sulcus, as it deepens the vestibule, thereby increasing the surface area available for better fitting of dentures or dental implants. The procedure can be categorized into anterior vestibuloplasty, which focuses on the area between the lips and the front teeth, and posterior vestibuloplasty, which addresses the tissue between the cheeks and the teeth. For the entire arch vestibuloplasty, an incision is made along the crest of the alveolar ridge and the unattached labiobuccal mucosa, extending from one retromolar pad to the other. This comprehensive approach allows for significant alterations to the vestibular area, enhancing both the aesthetic and functional aspects of the oral cavity.
© Copyright 2025 Coding Ahead. All rights reserved.
The vestibuloplasty procedure, specifically CPT® 40844, is indicated for various conditions and situations that necessitate surgical intervention in the vestibular area of the mouth. The following are the primary indications for performing this procedure:
The vestibuloplasty procedure coded as CPT® 40844 involves several detailed steps to ensure effective surgical outcomes. The following outlines the procedural steps involved:
Following the vestibuloplasty procedure, patients can expect specific post-operative care and considerations. It is essential to monitor the surgical site for any signs of infection or complications. Patients may be advised to follow a soft diet to minimize irritation to the surgical area during the initial healing phase. 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 typically removed approximately two weeks after the procedure, allowing for adequate healing and stabilization of the tissues involved.
| Short Descr | RECONSTRUCTION OF MOUTH | Medium Descr | VESTIBULOPLASTY ENTIRE ARCH | Long Descr | Vestibuloplasty; entire arch | 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) | 0 - 150% payment adjustment for bilateral procedures 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). | 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). | 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). | GC | This service has been performed in part by a resident under the direction of a teaching physician |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.