How To Use CPT Code 40808

CPT 40808 describes the biopsy procedure performed by a healthcare provider to obtain a sample of tissues from the vestibule of a patient’s mouth. 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 40808?

CPT 40808 can be used to describe the biopsy procedure performed by a healthcare provider to diagnose abnormal conditions in the mouth. This code is used when the provider excises a sample of tissues from the vestibule of the patient’s mouth for further examination.

2. Official Description

The official description of CPT code 40808 is: ‘Biopsy, vestibule of mouth.’

3. Procedure

1. The healthcare provider prepares and anesthetizes the patient for the biopsy procedure.
2. The provider performs an incision in the lesion area of the vestibule of the patient’s mouth.
3. The provider removes the lesion along with margins of healthy tissue.
4. The excised tissue is sent to the laboratory for testing and examination.
5. The provider performs this procedure to assess any unexplained oral mucosal abnormality.

4. Qualifying circumstances

Patients who may require CPT 40808 are those with unexplained oral mucosal abnormalities that need further examination. The procedure is performed by a healthcare provider to obtain a biopsy sample from the vestibule of the patient’s mouth.

5. When to use CPT code 40808

CPT code 40808 should be used when a healthcare provider performs a biopsy procedure to obtain a sample of tissues from the vestibule of the patient’s mouth. It should not be used for procedures involving the destruction of lesions or scars in the vestibule of the mouth.

6. Documentation requirements

To support a claim for CPT 40808, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the biopsy procedure
• Details of the biopsy procedure, including the incision and removal of the lesion
• Date and time of the procedure
• Results of the biopsy examination
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 40808, ensure that the procedure is performed by a healthcare provider and involves the biopsy of the vestibule of the patient’s mouth. It should not be reported with codes for the destruction of lesions or scars in the vestibule of the mouth. Additional tips for reporting CPT 40808 may include considerations for the use of lasers in the procedure.

8. Historical information

CPT 40808 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 healthcare provider performs a biopsy of the vestibule of a patient’s mouth to diagnose an abnormal condition.
2. During the biopsy procedure, the provider removes a sample of tissues from the vestibule of the patient’s mouth for further examination.
3. A patient with an unexplained oral mucosal abnormality undergoes a biopsy of the vestibule of their mouth to determine the cause of the condition.
4. The healthcare provider excises a lesion from the vestibule of the patient’s mouth and sends it to the laboratory for testing.
5. During the biopsy procedure, the provider removes a small portion of tissues from the vestibule of the patient’s mouth to assess any abnormalities.
6. A biopsy of the vestibule of the mouth is performed by a healthcare provider to obtain a sample for diagnostic purposes.
7. The provider performs a biopsy procedure to examine tissues from the vestibule of the patient’s mouth and determine the nature of any abnormalities.
8. A patient with an oral mucosal abnormality undergoes a biopsy of the vestibule of their mouth to aid in diagnosis and treatment planning.
9. The healthcare provider performs a biopsy of the vestibule of the patient’s mouth to investigate the presence of any abnormal conditions.
10. During the biopsy procedure, the provider removes a sample of tissues from the vestibule of the patient’s mouth to determine the cause of the oral mucosal abnormality.