How To Use CPT Code 40810

CPT 40810 describes the excision of a lesion or area of damaged or diseased tissue in the mucosa and submucosa of the vestibule of the mouth, without repair. 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 40810?

CPT 40810 is used to describe the excision of a lesion or area of damaged or diseased tissue in the mucosa and submucosa of the vestibule of the mouth. This procedure does not include repair of the surgical wound.

2. Official Description

The official description of CPT code 40810 is: ‘Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair.’

3. Procedure

1. The healthcare provider prepares and anesthetizes the patient.
2. Using a scalpel or needle-tipped electrocautery, the provider makes a superficial incision in the mucosal and submucosal area of the lesion.
3. The provider then removes the lesion along with its margins.
4. No repair of the surgical wound is performed.

4. Qualifying circumstances

CPT 40810 is performed when there is a need to excise a lesion or area of damaged or diseased tissue in the mucosa and submucosa of the vestibule of the mouth. This code does not include repair of the surgical wound.

5. When to use CPT code 40810

CPT code 40810 should be used when the healthcare provider performs an excision of a lesion or area of damaged or diseased tissue in the mucosa and submucosa of the vestibule of the mouth, without performing any repair of the surgical wound.

6. Documentation requirements

To support a claim for CPT 40810, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for excision of the lesion
• Details of the procedure, including the use of scalpel or needle-tipped electrocautery
• Date of the procedure
• Any additional relevant information
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 40810, ensure that the procedure performed is the excision of a lesion or area of damaged or diseased tissue in the mucosa and submucosa of the vestibule of the mouth, without any repair. There is no need to report a separate code for wound closure, as it is included in this code.

8. Historical information

CPT 40810 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 an excision of a lesion in the mucosa and submucosa of the vestibule of the mouth, without repair.
2. A patient undergoes the removal of a damaged area of tissue in the mucosa and submucosa of the vestibule of the mouth, without any repair.
3. A lesion in the mucosa and submucosa of the vestibule of the mouth is excised by a healthcare provider, without performing any repair.
4. An area of diseased tissue in the mucosa and submucosa of the vestibule of the mouth is removed by a healthcare provider, without any repair.
5. A healthcare provider performs an excision of a lesion in the mucosa and submucosa of the vestibule of the mouth, without performing any repair of the surgical wound.
6. A patient undergoes the removal of a damaged area of tissue in the mucosa and submucosa of the vestibule of the mouth, without any repair of the surgical wound.
7. A lesion in the mucosa and submucosa of the vestibule of the mouth is excised by a healthcare provider, without performing any repair of the surgical wound.
8. An area of diseased tissue in the mucosa and submucosa of the vestibule of the mouth is removed by a healthcare provider, without any repair of the surgical wound.
9. A healthcare provider performs an excision of a lesion in the mucosa and submucosa of the vestibule of the mouth, without performing any repair.
10. A patient undergoes the removal of a damaged area of tissue in the mucosa and submucosa of the vestibule of the mouth, without any repair.