Coding Ahead
CasePilot
Medical Coding Assistant
Case2Code
Search and Code Lookup Tool
RedactPHI
HIPAA-Compliant PHI Redaction
DetectICD10CM
ICD-10-CM Code Detection
Log in Register free account
1 code page views remaining. Guest accounts are limited to 1 page view. Register free account to get 5 more views.
Log in Register free account

Official Description

Excision of lesion or tumor (except listed above), dentoalveolar structures; with complex repair

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 41827 involves the excision of a lesion or tumor located within the dentoalveolar structures, which include the gums and the supporting bone of the teeth. This procedure is specifically indicated when a lesion or tumor is present that requires surgical removal due to its size, type, or location. The term 'complex repair' refers to the method used to close the surgical site after the excision, which may involve techniques that require more extensive suturing or tissue manipulation compared to a simple repair. It is important to differentiate this code from CPT® Code 41826, which is used when the excision is followed by a simpler closure method. The complexity of the repair is a critical factor in determining the appropriate coding for the procedure, as it impacts the overall surgical approach and the resources required for patient care.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The excision of lesions or tumors from the dentoalveolar structures is typically indicated in the following scenarios:

  • Presence of Lesion or Tumor The procedure is performed when a lesion or tumor is identified in the gums or surrounding dental structures that may pose a risk to oral health or require removal for diagnostic purposes.
  • Size and Type of Lesion Larger or more complex lesions that cannot be adequately treated with less invasive methods may necessitate excision.
  • Symptoms Symptoms such as pain, swelling, or infection associated with the lesion may also warrant surgical intervention.

2. Procedure

The procedure for excising a lesion or tumor from the dentoalveolar structures with a complex repair involves several key steps:

  • Step 1: Anesthesia Administration The procedure begins with the administration of local anesthesia to ensure the patient is comfortable and pain-free during the excision. This is crucial for minimizing discomfort and facilitating a smooth surgical process.
  • Step 2: Incision A careful incision is made around the lesion or tumor to access the affected tissue. The incision must be precise to ensure complete removal of the lesion while preserving surrounding healthy tissue.
  • Step 3: Excision of the Lesion The lesion or tumor is then excised from the dentoalveolar structures. This step requires careful dissection to ensure that the entire lesion is removed, which may involve cutting through various layers of tissue.
  • Step 4: Hemostasis After the lesion is removed, hemostasis is achieved to control any bleeding. This may involve cauterization or the application of sutures to secure blood vessels.
  • Step 5: Complex Repair Following excision, a complex repair is performed to close the surgical site. This may involve multiple layers of suturing and careful alignment of the tissue to promote optimal healing and aesthetic outcomes.
  • Step 6: Post-Operative Care Instructions Finally, the patient is provided with post-operative care instructions, which may include guidance on pain management, oral hygiene, and signs of complications to monitor.

3. Post-Procedure

After the excision and complex repair, patients can expect a recovery period that may vary depending on the extent of the surgery and individual healing responses. Post-operative care typically includes managing discomfort with prescribed pain medications, maintaining oral hygiene to prevent infection, and attending follow-up appointments to monitor healing. Patients should be advised to avoid certain activities, such as vigorous physical exercise or consuming hard foods, that could disrupt the surgical site. Additionally, any signs of complications, such as excessive bleeding, increased pain, or signs of infection, should be reported to the healthcare provider promptly for further evaluation.

Short Descr EXCISION OF GUM LESION
Medium Descr EXC LESION/TUMOR DENTALVEOLAR STRUX W/CMPLX RPR
Long Descr Excision of lesion or tumor (except listed above), dentoalveolar structures; with complex repair
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 29 - Oral and Dental Services
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.)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CR Catastrophe/disaster related
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
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)
Date
Action
Notes
Pre-1990 Added Code added.
Code
Description
Code
Description
Code
Description
Code
Description
Code
Description
CasePilot

Get instant expert-level medical coding assistance.

Ask about:
CPT Codes Guidelines Modifiers Crosswalks NCCI Edits Compliance Medicare Coverage
Example: "What is CPT code 99213?" or "Guidelines for E/M services"