How To Use CPT Code 21040

CPT 21040 describes the excision of a benign tumor or cyst of the mandible through enucleation and/or curettage. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 21040?

CPT 21040 is used to describe the excision of a benign tumor or cyst of the mandible. This procedure involves the removal of the tumor or cyst through enucleation and/or curettage. Enucleation refers to the removal of the entire tumor as a single mass, while curettage involves scraping the diseased tissue using a curette, a spoon-shaped surgical instrument.

2. Official Description

The official description of CPT code 21040 is: ‘Excision of benign tumor or cyst of mandible, by enucleation and/or curettage. For enucleation and/or curettage of benign cysts or tumors of the mandible not requiring osteotomy, use 21040. For excision of benign tumor or cyst of mandible requiring osteotomy, see 21046 – 21047.’

3. Procedure

The procedure for CPT code 21040 involves the following steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision through the oral mucosa or the skin of the face, depending on the approach.
3. The provider locates the tumor on the mandible and marks it for dissection.
4. The tumor is dissected from the surrounding tissue and removed in its entirety.
5. A curette is used to scrape the surrounding tissues to ensure complete removal of the tumor.
6. A tissue specimen is submitted for laboratory analysis.
7. The provider checks for bleeding, removes any instruments, and closes the incision by suturing in a layered fashion.

4. Qualifying circumstances

CPT 21040 is used for the excision of benign tumors or cysts of the mandible that do not require osteotomy. It is important to note that this code is specifically for benign conditions and not for cancerous tumors. The procedure must involve enucleation and/or curettage, and the tumor or cyst must be located on the mandible.

5. When to use CPT code 21040

CPT code 21040 should be used when a provider performs the excision of a benign tumor or cyst of the mandible through enucleation and/or curettage. It is important to ensure that the condition being treated is benign and does not require osteotomy. If osteotomy is required, different codes (21046 – 21047) should be used.

6. Documentation requirements

To support a claim for CPT 21040, the provider must document the following information:

• Patient’s diagnosis indicating the presence of a benign tumor or cyst of the mandible
• Details of the procedure performed, including the approach used (intraoral or extraoral)
• Location of the tumor or cyst on the mandible
• Extent of the enucleation and/or curettage performed
• Submission of a tissue specimen for laboratory analysis
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 21040, it is important to ensure that the procedure meets the criteria outlined in the code description. This includes the excision of a benign tumor or cyst of the mandible through enucleation and/or curettage. It is also important to use the appropriate code based on the specific circumstances of the procedure. If osteotomy is required, different codes should be used (21046 – 21047).

8. Historical information

CPT 21040 was added to the Current Procedural Terminology system on January 1, 1990. There have been historical changes to the code, including a code change on January 1, 2003, which clarified the excision of benign cysts or tumors of the mandible.

9. Examples

1. A patient undergoes the excision of a benign tumor of the mandible through enucleation.
2. A provider performs the curettage of a benign cyst on the mandible.
3. A patient requires the enucleation and curettage of a benign tumor on the mandible.
4. A provider performs the excision of a benign cyst of the mandible through enucleation and curettage.
5. A patient undergoes the enucleation of a benign tumor on the mandible.
6. A provider performs the curettage of a benign cyst on the mandible.
7. A patient requires the enucleation and curettage of a benign tumor on the mandible.
8. A provider performs the excision of a benign cyst of the mandible through enucleation and curettage.
9. A patient undergoes the enucleation of a benign tumor on the mandible.
10. A provider performs the curettage of a benign cyst on the mandible.