How To Use CPT Code 40804

CPT 40804 describes the removal of an embedded foreign body in the vestibule of the mouth through a simple procedure. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 40804?

CPT 40804 can be used to describe the removal of an embedded foreign body in the vestibule of the mouth. This procedure is considered simple and involves the extraction of a foreign object that does not require complicated techniques or access.

2. Official Description

The official description of CPT code 40804 is the “Removal of embedded foreign body, vestibule of mouth; simple.” This code specifically refers to the extraction of a foreign object from the vestibule or anterior portion of the oral cavity.

3. Procedure

1. The provider ensures that the patient is properly prepped and anesthetized.
2. The patient is asked to open their mouth wide to allow for better access to the foreign body.
3. If the object is easily visible and reachable, the provider may use forceps to grasp and remove it.
4. If the object is not easily accessible, the provider may need to make an incision over the area where the foreign body is located to free it.
5. Once the object is freed, the provider uses forceps to grasp and remove it.
6. After the removal, the provider may apply antiseptic or bandages to the area as necessary for healing.

4. Qualifying circumstances

CPT 40804 is applicable when there is an embedded foreign body in the vestibule of the mouth that requires removal. The procedure is considered simple, meaning that it does not involve complex techniques or difficult access. The foreign body can be any material substance that has been accidentally introduced into the tissues or cavities of the mouth.

5. When to use CPT code 40804

CPT code 40804 should be used when a provider performs a simple removal of an embedded foreign body in the vestibule of the mouth. It is important to note that this code is not appropriate for complicated procedures where the foreign body is large or difficult to access. In such cases, CPT code 40805 should be used instead.

6. Documentation requirements

To support a claim for CPT 40804, the provider must document the following information:

• The presence of an embedded foreign body in the vestibule of the mouth
• The use of forceps or other instruments for removal
• Details of any incisions made, if applicable
• The date and duration of the procedure
• Any additional treatments or interventions performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 40804, ensure that the procedure performed is a simple removal of an embedded foreign body in the vestibule of the mouth. It is important to note that CPT code 40804 should not be reported with other codes unless necessary. Additionally, consider using modifier TC for the technical component and modifier 26 for the professional component, if applicable.

8. Historical information

CPT 40804 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A dentist removing a small piece of food stuck in the vestibule of a patient’s mouth.
2. An oral surgeon extracting a splinter from the gum area of a patient’s mouth.
3. A maxillofacial surgeon removing a small bone fragment from the vestibule of a patient’s mouth.
4. A pediatric dentist extracting a small toy part from the cheek area of a child’s mouth.
5. An otolaryngologist removing a metal fragment from the lip area of a patient’s mouth.
6. A dental hygienist extracting a foreign object from the gumline of a patient’s mouth.
7. An oral and maxillofacial surgeon removing a small glass shard from the vestibule of a patient’s mouth.
8. A general dentist extracting a small piece of plastic from the cheek area of a patient’s mouth.
9. An oral surgeon removing a small wooden splinter from the gum area of a patient’s mouth.
10. A maxillofacial surgeon extracting a small metal fragment from the vestibule of a patient’s mouth.