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Official Description

Periodontal mucosal grafting

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Periodontal mucosal grafting is a surgical procedure that involves the transplantation of tissue onto the gums. This procedure is typically performed to address issues such as gum recession or to enhance the thickness of the gum tissue. The grafted tissue can be sourced from the patient's own mouth, often from the palate, or it may be obtained from a donor. The primary goal of this procedure is to restore the health and aesthetics of the gums, providing better support for the teeth and improving overall oral health. By reinforcing the gum tissue, periodontal mucosal grafting can help prevent further gum recession and associated complications, thereby contributing to the long-term stability of the periodontal structures. This procedure is particularly relevant in cases where the existing gum tissue is insufficient to adequately protect the underlying bone and tooth roots.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure of periodontal mucosal grafting is indicated for several specific conditions related to gum health and aesthetics. These indications include:

  • Gum Recession - This condition occurs when the gum tissue pulls back from the teeth, exposing the roots and potentially leading to sensitivity and decay.
  • Insufficient Gum Tissue - Patients may require additional gum tissue to provide adequate coverage and support for the teeth, particularly in areas where the gum is thin or lacking.
  • Periodontal Disease - Individuals with a history of periodontal disease may benefit from grafting to restore lost gum tissue and improve periodontal health.
  • Cosmetic Concerns - Patients seeking to enhance the appearance of their smile may opt for this procedure to improve the aesthetics of their gum line.

2. Procedure

The procedure of periodontal mucosal grafting involves several key steps that ensure the successful transplantation of tissue onto the gums. These steps include:

  • Step 1: Anesthesia Administration - The procedure begins with the administration of local anesthesia to ensure the patient is comfortable and pain-free during the surgery. This is crucial for minimizing discomfort and anxiety.
  • Step 2: Graft Harvesting - The surgeon then carefully harvests the graft tissue, which can be taken from the patient's palate or may be sourced from a donor. The selection of the graft site is based on the specific needs of the patient and the amount of tissue required.
  • Step 3: Preparation of the Recipient Site - The area of the gum where the graft will be placed is prepared by gently cleaning and shaping the tissue to ensure proper integration of the graft.
  • Step 4: Graft Placement - The harvested graft is then meticulously placed onto the prepared recipient site. The surgeon ensures that the graft is positioned correctly to promote healing and integration with the existing gum tissue.
  • Step 5: Securing the Graft - The graft is secured in place using sutures or other fixation methods to prevent movement and to facilitate healing. This step is critical for the success of the graft.
  • Step 6: Post-Operative Care Instructions - After the procedure, the patient is provided with detailed post-operative care instructions to promote healing and minimize complications.

3. Post-Procedure

Following periodontal mucosal grafting, patients can expect a recovery period that may involve some swelling, discomfort, and bleeding. It is essential for patients to adhere to the post-operative care instructions provided by their healthcare provider, which may include recommendations for pain management, dietary modifications, and oral hygiene practices. Regular follow-up appointments will be necessary to monitor the healing process and ensure the graft is integrating properly with the surrounding gum tissue. Patients should also be aware of any signs of complications, such as excessive bleeding or infection, and report these to their healthcare provider promptly.

Short Descr PERIODONTAL MUCOSAL GRAFTING
Medium Descr PERIODONTAL MUCOSAL GRAFTING
Long Descr Periodontal mucosal grafting
Status Code Restricted Coverage
Global Days 000 - Endoscopic or 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 Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P1G - Major procedure - Other
MUE 2
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).
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.
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
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2025-01-01 Changed Short Description changed.
Pre-1990 Added Code added.
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