How To Use CPT Code 40844

CPT 40844 describes a specific procedure known as vestibuloplasty, which aims to improve the height of the alveolar ridge in the mouth. This article will provide an overview of CPT code 40844, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 40844?

CPT 40844 is a code that represents a surgical procedure called vestibuloplasty. This procedure is performed to enhance the height of the alveolar ridge, which is the ridge-like border on the upper and lower jaw that contains tooth sockets. Vestibuloplasty specifically focuses on the entire arch of the vestibule of the mouth, also known as the oral vestibule. By making the vestibule deeper, the provider can improve the height of the alveolar ridge.

2. Official Description

The official description of CPT code 40844 is: ‘Vestibuloplasty; entire arch.’

3. Procedure

1. To perform vestibuloplasty (CPT 40844), the provider begins by preparing and anesthetizing the patient.
2. Next, the provider makes an incision and dissects the mucosa along the entire arch of the vestibule of the mouth.
3. The mucosa is then freed from the underlying bone, allowing the provider to move it deep into the mouth.
4. If necessary, the provider rearranges the tissue to achieve the desired outcome.
5. In some cases, a splint may be placed in the mouth, which will be removed during a follow-up visit.
6. Vestibuloplasty can be beneficial for patients who have difficulty wearing dental devices like dentures or those who require reconstructive surgery after trauma or lesion removal.

4. Qualifying circumstances

Vestibuloplasty (CPT 40844) is typically performed on patients who require an improvement in the height of their alveolar ridge. This procedure may be necessary for individuals with anatomical challenges that make it difficult to wear dental devices or for those who need reconstructive surgery after trauma or lesion removal.

5. When to use CPT code 40844

CPT code 40844 should be used when a provider performs vestibuloplasty on the entire arch of the vestibule of the mouth. It is important to note that there are separate codes for anterior vestibuloplasty (CPT 40840), posterior unilateral vestibuloplasty (CPT 40842), posterior bilateral vestibuloplasty (CPT 40843), and complex vestibuloplasty (CPT 40845). Therefore, CPT 40844 specifically applies to vestibuloplasty of the entire arch.

6. Documentation requirements

When documenting a claim for CPT 40844, the provider should include the following information:

• Patient’s diagnosis or condition necessitating vestibuloplasty
• Details of the procedure performed, including any modifications or additional techniques used
• Date of the procedure
• Any specific challenges or complexities encountered during the procedure
• Post-operative instructions or recommendations
• Provider’s signature

7. Billing guidelines

When billing for CPT 40844, it is important to ensure that the procedure performed aligns with the official description of the code. Additionally, providers should follow any specific billing guidelines provided by their respective payers. It is also essential to review any bundling or unbundling rules that may apply to CPT 40844. For example, if a complex vestibuloplasty (CPT 40845) is performed, it should not be reported separately with CPT 40844.

8. Historical information

CPT 40844 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 patient with severe atrophy of the alveolar ridge undergoes vestibuloplasty (CPT 40844) to improve the height of the ridge and facilitate the use of dentures.
2. Following the removal of a lesion in the oral vestibule, a patient requires vestibuloplasty (CPT 40844) to reconstruct the area and restore the height of the alveolar ridge.
3. An individual with a congenital condition that affects the oral vestibule undergoes vestibuloplasty (CPT 40844) to enhance the height of the alveolar ridge and improve oral function.
4. After trauma resulting in significant damage to the oral vestibule, a patient undergoes vestibuloplasty (CPT 40844) to reconstruct the area and restore the height of the alveolar ridge.
5. A patient with a history of wearing dentures experiences discomfort due to a shallow vestibule, leading to the need for vestibuloplasty (CPT 40844) to deepen the vestibule and improve denture retention.