How To Use CPT Code 40845

CPT 40845 describes a surgical procedure known as vestibuloplasty, which is performed to improve the height of the alveolar ridge. This article will provide an overview of CPT code 40845, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes.

1. What is CPT Code 40845?

CPT 40845 is a code used to describe a surgical procedure called vestibuloplasty. This procedure aims to enhance the height of the alveolar ridge through various methods. It is typically performed in cases where patients have difficulty wearing dental devices, such as dentures, or when reconstructive surgery is required after trauma or lesion removal.

2. Official Description

The official description of CPT code 40845 is: ‘Vestibuloplasty; complex (including ridge extension, muscle repositioning).’ This code specifically applies to complex vestibuloplasty procedures that involve extending the ridge or repositioning muscles. It is important to note that this code does not cover skin grafts, which have their own set of codes (15002 et seq).

3. Procedure

1. During a vestibuloplasty procedure, the provider begins by making an incision in the mucosal layer over the alveolar ridge.
2. They then remove any excess mucosa or reposition it as necessary.
3. The provider proceeds to make an incision down to the muscles and detaches them.
4. Next, they lengthen and reattach the muscles, widening the vestibule of the mouth and improving the height of the alveolar ridge.
5. After ensuring there is no bleeding, the provider removes all instruments and closes the incision in the alveolar ridge with sutures in layers.

4. Qualifying circumstances

Vestibuloplasty procedures, including those described by CPT code 40845, are typically performed on patients who require improvement in the height of their alveolar ridge. This procedure may be necessary for patients who have difficulty wearing dental devices or those who need reconstructive surgery after trauma or lesion removal. It is important to note that anterior vestibuloplasty, posterior vestibuloplasty on one side of the back jaw, posterior vestibuloplasty on both sides of the back jaw, and vestibuloplasty of the entire arch have their own specific codes.

5. When to use CPT code 40845

CPT code 40845 should be used when a complex vestibuloplasty procedure is performed, involving ridge extension and muscle repositioning. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the procedure does not involve complex vestibuloplasty, a different code should be used.

6. Documentation requirements

When reporting CPT code 40845, the following documentation should be included:

• Patient’s diagnosis and the need for vestibuloplasty
• Details of the procedure performed, including ridge extension and muscle repositioning
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT code 40845, it is important to ensure that the procedure meets the criteria for complex vestibuloplasty. Additionally, it is crucial to follow any specific guidelines provided by the payer. It is also important to note that CPT code 40845 should not be reported with other codes unless they are performed in the previous seven days.

8. Historical information

CPT code 40845 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 a history of trauma requires vestibuloplasty to improve the height of their alveolar ridge.
2. A patient who has difficulty wearing dentures undergoes a complex vestibuloplasty procedure to enhance the height of their alveolar ridge.
3. A provider performs vestibuloplasty on a patient who requires reconstructive surgery after the removal of a lesion.
4. A complex vestibuloplasty procedure is performed on a patient with congenital abnormalities affecting the alveolar ridge.
5. A patient with a history of oral cancer undergoes vestibuloplasty as part of their reconstructive surgery.
6. A provider performs vestibuloplasty on a patient with severe gum disease to improve the height of their alveolar ridge.
7. A patient with a congenital condition that affects the development of the alveolar ridge undergoes vestibuloplasty to enhance their oral function.
8. A provider performs vestibuloplasty on a patient who requires dental implants but lacks sufficient alveolar ridge height.
9. A patient with a history of oral trauma undergoes vestibuloplasty to restore the height of their alveolar ridge.
10. A complex vestibuloplasty procedure is performed on a patient with a congenital defect affecting the development of their alveolar ridge.