How To Use CPT Code 40490

CPT 40490 describes the procedure for a biopsy of the lip, which involves the removal of a sample of tissue from the lip for diagnostic purposes. This article will cover the description, official terminology, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 40490?

CPT 40490 is used to describe the biopsy of the lip, where a healthcare provider removes a sample of tissue from the lip for diagnostic purposes. This code is used when the provider makes an elliptical incision on the lip, removes the lesion along with margins of healthy tissue, and stops any bleeding using chemo or electrocautery if necessary.

2. Official Description

The official description of CPT code 40490 is: ‘Biopsy of lip; excision of lesion, papular lesion.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an elliptical incision on the lip using a scalpel.
3. The provider continues the dissection using scissors to identify and remove the lesion.
4. If necessary, the provider stops any bleeding using chemo or electrocautery.

4. Qualifying circumstances

CPT 40490 is performed when a patient requires a biopsy of a lesion on the lip for diagnostic purposes. The provider must make an elliptical incision, remove the lesion along with margins of healthy tissue, and may use chemo or electrocautery to stop any bleeding.

5. When to use CPT code 40490

CPT code 40490 should be used when a biopsy of the lip is performed, specifically for the excision of a papular lesion. This code is not appropriate for other excision procedures on the lip, which have their own range of codes (40500-40530).

6. Documentation requirements

To support a claim for CPT 40490, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the lip biopsy
• Details of the procedure, including the elliptical incision, removal of the lesion, and any use of chemo or electrocautery
• Date and time of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the biopsy

7. Billing guidelines

When billing for CPT 40490, ensure that the procedure meets the requirements of the code, including the excision of a papular lesion on the lip. It is important to note that CPT code 40490 should not be reported with other excision codes for the lip (40500-40530).

8. Historical information

CPT 40490 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A dermatologist performs a biopsy of a papular lesion on a patient’s lip for diagnostic purposes.
2. An oral surgeon removes a papular lesion from a patient’s lip and sends it for further analysis.
3. A plastic surgeon excises a papular lesion on a patient’s lip and performs a biopsy to determine its nature.
4. A maxillofacial surgeon performs a biopsy of a papular lesion on a patient’s lip to rule out any malignancy.
5. An otolaryngologist removes a papular lesion from a patient’s lip and performs a biopsy to assess its characteristics.
6. A general surgeon excises a papular lesion on a patient’s lip and sends it for histopathological examination.
7. A dermatopathologist performs a biopsy of a papular lesion on a patient’s lip to aid in the diagnosis.
8. An oral pathologist removes a papular lesion from a patient’s lip and examines it under a microscope for further evaluation.
9. A plastic surgeon excises a papular lesion on a patient’s lip and performs a biopsy to determine the appropriate treatment plan.
10. A maxillofacial surgeon performs a biopsy of a papular lesion on a patient’s lip to confirm the presence of a specific condition.