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The CPT® Code 41828 refers to the excision of hyperplastic alveolar mucosa, which involves the surgical removal of excess tissue from the alveolar mucosa in the mouth. This procedure is typically performed in cases where there is an overgrowth of tissue, often referred to as hyperplasia, which can occur in the areas surrounding tooth sockets. The term "alveolar mucosa" specifically refers to the mucous membrane that lines the alveolar processes of the jaw, where the teeth are anchored. The procedure is performed in quadrants of the mouth, meaning that it can be executed in one or more sections, depending on the extent of the hyperplastic tissue present. Each quadrant is treated as a separate entity for billing purposes, allowing the procedure to be reported once for each quadrant that is operated on. This ensures that the surgical intervention is accurately documented and billed according to the specific areas treated.
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The excision of hyperplastic alveolar mucosa, coded as CPT® 41828, is indicated for patients presenting with excessive tissue growth in the alveolar mucosa. This condition may arise due to various factors, including chronic irritation, inflammation, or other underlying dental issues. The procedure is typically performed when the hyperplastic tissue interferes with normal oral function, causes discomfort, or poses a risk for further complications. The following are specific indications for this procedure:
The procedure for excising hyperplastic alveolar mucosa involves several key steps, each critical to ensuring the successful removal of the excess tissue. The following outlines the procedural steps as described:
Post-procedure care following the excision of hyperplastic alveolar mucosa is essential for optimal recovery. Patients are typically advised to follow specific guidelines to promote healing and minimize discomfort. These may include recommendations for pain management, such as the use of prescribed analgesics, and instructions on maintaining oral hygiene without disturbing the surgical site. Patients may also be advised to avoid certain foods that could irritate the area and to refrain from vigorous physical activity for a specified period. Follow-up appointments may be scheduled to monitor the healing process and address any concerns that may arise during recovery.
| Short Descr | EXCISION OF GUM LESION | Medium Descr | EXC HYPRPLSTC ALVEOLAR MUCOSA EA QUADRANT SPEC | Long Descr | Excision of hyperplastic alveolar mucosa, each quadrant (specify) | Status Code | Restricted Coverage | 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 | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6D - Minor procedures - other (non-Medicare fee schedule) | MUE | 4 | CCS Clinical Classification | 29 - Oral and Dental Services |
| 47 | Anesthesia by surgeon: regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (this does not include local anesthesia.) note: modifier 47 would not be used as a modifier for the anesthesia procedures. | 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). | 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. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 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 | 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) |
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| Pre-1990 | Added | Code added. |
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