How To Use CPT Code 41828

CPT 41828 describes the excision of hyperplastic alveolar mucosa in a single quadrant of the dentoalveolar structures. 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 41828?

CPT 41828 is used to describe the excision of hyperplastic alveolar mucosa in a single quadrant of the dentoalveolar structures. This procedure involves the removal of excessive mucosa using a sharp knife or similar tool. It is typically performed when there is an aberrant increase in the number of normal cells in the mucosa lining the dental alveoli.

2. Official Description

The official description of CPT code 41828 is: ‘Excision of hyperplastic alveolar mucosa, each quadrant (specify).’ This code is used when the provider cuts away the hyperplastic mucosa in a single quadrant using a sharp knife or other implement.

3. Procedure

1. When performing CPT 41828, the provider begins by appropriately prepping and anesthetizing the patient.
2. An incision is made in the hyperplastic mucosa, which is an overgrowth of the moist mucous membrane.
3. The provider then separates the hyperplastic mucosa from the normal mucosa.
4. Using a sharp knife or similar tool, the provider removes the hyperplastic mucosa.
5. After removing the excessive mucosa, the provider checks for any bleeding and removes any instruments used during the procedure.
6. If necessary, the provider closes the incision in the mucosa.

4. Qualifying circumstances

CPT 41828 is performed on patients who have hyperplastic alveolar mucosa in a single quadrant of the dentoalveolar structures. This procedure is indicated when there is an aberrant increase in the number of normal cells in the mucosa lining the dental alveoli. It is important to note that this code is specific to each quadrant, so multiple procedures may be required if hyperplastic mucosa is present in multiple quadrants.

5. When to use CPT code 41828

CPT code 41828 should be used when the provider performs the excision of hyperplastic alveolar mucosa in a single quadrant of the dentoalveolar structures. It is important to accurately document the specific quadrant where the procedure was performed.

6. Documentation requirements

To support a claim for CPT 41828, the provider must document the following information:

• The patient’s diagnosis indicating the presence of hyperplastic alveolar mucosa
• The specific quadrant where the excision was performed
• The date of the procedure
• A detailed description of the procedure, including the use of a sharp knife or similar tool
• Any additional procedures performed, such as closing the incision in the mucosa
• The provider’s signature

7. Billing guidelines

When billing for CPT 41828, ensure that the excision is performed in a single quadrant of the dentoalveolar structures. It is important to report surgery in each quadrant separately. There are no specific guidelines regarding reporting CPT 41828 with other codes, so it should be reported as a standalone procedure.

8. Historical information

CPT 41828 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 dentist performing the excision of hyperplastic alveolar mucosa in the upper right quadrant of a patient’s mouth.
2. An oral surgeon removing excessive mucosa in the lower left quadrant of a patient’s dentoalveolar structures.
3. A maxillofacial surgeon excising hyperplastic alveolar mucosa in the upper left quadrant of a patient’s mouth.
4. A periodontist performing the excision of hyperplastic alveolar mucosa in the lower right quadrant of a patient’s dentoalveolar structures.
5. An oral and maxillofacial pathologist removing excessive mucosa in the upper right quadrant of a patient’s mouth.
6. A general dentist excising hyperplastic alveolar mucosa in the lower left quadrant of a patient’s dentoalveolar structures.
7. An oral surgeon performing the excision of hyperplastic alveolar mucosa in the upper left quadrant of a patient’s mouth.
8. A maxillofacial surgeon removing excessive mucosa in the lower right quadrant of a patient’s dentoalveolar structures.
9. A periodontist excising hyperplastic alveolar mucosa in the upper right quadrant of a patient’s mouth.
10. An oral and maxillofacial pathologist removing excessive mucosa in the lower left quadrant of a patient’s dentoalveolar structures.