How To Use CPT Code 40818

CPT 40818 describes the excision of mucosa from the vestibule of the mouth to be used as a graft in a different location within the mouth. 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 40818?

CPT 40818 can be used to describe the excision of mucosa from the vestibule of the mouth for the purpose of using it as a graft in another area of the mouth. This code is used when the provider removes the mucosal tissues from the lips and cheeks in the vestibule and prepares it to be used as a graft in a separate procedure.

2. Official Description

The official description of CPT code 40818 is: ‘Excision of mucosa of vestibule of mouth as donor graft.’

3. Procedure

1. The provider begins by preparing the patient and administering anesthesia.
2. Using a retractor, the provider gains access to the vestibule of the mouth.
3. With a scalpel, the provider makes an incision in the mucosa of the lips and cheeks in the vestibule.
4. The provider then carefully removes the mucosa from the surrounding structures.
5. The excised mucosa is prepared to be used as a graft in a separate procedure.
6. The provider cleans the site and closes the wound.

4. Qualifying circumstances

CPT 40818 is used when the provider needs to harvest mucosa from the vestibule of the mouth to be used as a graft in another area of the mouth. This procedure is typically performed when there is a need to repair or replace defective or missing tissue or structure with the harvested mucosa. The vestibule of the mouth refers to the space between the cheeks and the teeth.

5. When to use CPT code 40818

CPT code 40818 should be used when the provider performs the excision of mucosa from the vestibule of the mouth specifically for the purpose of using it as a graft in another area of the mouth. It should not be used when the excision is performed to remove a lesion in the vestibule of the mouth.

6. Documentation requirements

To support a claim for CPT 40818, the provider must document the following information:

• Reason for the excision and the need for a graft
• Details of the excision procedure, including the location and size of the excised mucosa
• Documentation of the separate procedure in which the graft is used
• Date of the procedure
• Signature of the provider performing the excision

7. Billing guidelines

When billing for CPT 40818, ensure that the excision is performed specifically for the purpose of using the mucosa as a graft in another area of the mouth. It should not be reported if the excision is performed to remove a lesion. There are no specific guidelines regarding reporting CPT 40818 with other codes.

8. Historical information

CPT 40818 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 provider performs the excision of mucosa from the vestibule of the mouth to use as a graft in the reconstruction of a cleft palate.
2. During a surgical procedure, a provider harvests mucosa from the vestibule of the mouth to use as a graft in the repair of a defect in the oral cavity.
3. A patient undergoes an excision of mucosa from the vestibule of the mouth to be used as a graft in the reconstruction of a damaged gum tissue.
4. A provider performs the excision of mucosa from the vestibule of the mouth to use as a graft in the repair of a traumatic injury to the oral cavity.
5. During a reconstructive surgery, a provider removes mucosa from the vestibule of the mouth to be used as a graft in the reconstruction of a missing tissue in the oral cavity.
6. A patient undergoes an excision of mucosa from the vestibule of the mouth to be used as a graft in the repair of a congenital defect in the oral cavity.
7. A provider performs the excision of mucosa from the vestibule of the mouth to use as a graft in the reconstruction of a damaged salivary gland.
8. During a surgical procedure, a provider harvests mucosa from the vestibule of the mouth to use as a graft in the repair of a defect in the tongue.
9. A patient undergoes an excision of mucosa from the vestibule of the mouth to be used as a graft in the reconstruction of a damaged jaw bone.
10. A provider performs the excision of mucosa from the vestibule of the mouth to use as a graft in the repair of a defect in the hard palate.