How To Use CPT Code 41870

CPT 41870 describes the procedure of periodontal mucosal grafting, which involves the removal of mouth tissue, typically from the roof of the mouth, and grafting it to the root of the tooth or teeth. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 41870?

CPT 41870 is used to describe the procedure of periodontal mucosal grafting. This involves the provider removing mucosal tissue from an area such as the roof of the mouth and grafting it to the roots of the teeth to cover areas with lost gum tissues. The procedure aims to repair or replace defective or missing gum tissue with the use of another material, such as artificial material or harvested tissue.

2. Official Description

The official description of CPT code 41870 is: ‘Periodontal mucosal grafting, which involves the removal of mouth tissue, typically from the roof of the mouth, and grafting it to the root of the tooth or teeth.’

3. Procedure

1. When performing periodontal mucosal grafting, the provider begins by appropriately prepping and anesthetizing the patient.
2. An incision is made in the donor area, which is usually the roof of the mouth.
3. The provider then uses a scalpel to carefully remove the mucosal tissue from the donor area.
4. The harvested mucosal tissue is then grafted onto the roots of the teeth to cover the areas with lost gum tissues.
5. The provider checks for any bleeding and ensures that all instruments are removed.
6. Finally, the incision in the alveolar process is closed.

4. Qualifying circumstances

CPT 41870 is performed when there is a need to repair or replace gum tissue that has been lost or is defective. The procedure is typically done for patients with periodontal conditions or diseases affecting the teeth and their supporting structures. It is important to note that the provider must use another material, such as artificial material or harvested tissue, to graft onto the roots of the teeth.

5. When to use CPT code 41870

CPT code 41870 should be used when the provider performs periodontal mucosal grafting to repair or replace gum tissue. It is important to ensure that the procedure involves the removal of mouth tissue, typically from the roof of the mouth, and grafting it to the root of the tooth or teeth. If the provider alters the gum contours without performing grafting, a different code, such as 41872, should be used.

6. Documentation requirements

To support a claim for CPT 41870, the provider must document the following information:

• Patient’s diagnosis and the need for periodontal mucosal grafting
• Specific details of the procedure, including the location of the donor area and the roots of the teeth where the grafting was performed
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 41870, ensure that the procedure involves the removal of mouth tissue and grafting it to the root of the tooth or teeth. It is important to use the appropriate code based on the specific procedure performed. If the provider alters the gum contours without performing grafting, a different code, such as 41872, should be used. It is also important to follow any additional guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 41870 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 periodontist performing periodontal mucosal grafting to repair gum tissue loss in a patient with severe periodontal disease.
2. An oral surgeon grafting mucosal tissue from the roof of the mouth to cover exposed tooth roots in a patient with gum recession.
3. A prosthodontist performing periodontal mucosal grafting as part of a full mouth reconstruction procedure to improve the appearance and function of the gums.
4. A general dentist grafting mucosal tissue onto the roots of a tooth after a traumatic injury resulted in gum tissue loss.
5. An oral and maxillofacial surgeon performing periodontal mucosal grafting to prepare the gums for dental implant placement.
6. A periodontist performing periodontal mucosal grafting to repair gum tissue loss caused by aggressive tooth brushing habits in a patient.
7. An oral surgeon grafting mucosal tissue onto the roots of multiple teeth to improve the aesthetics of the patient’s smile.
8. A general dentist performing periodontal mucosal grafting to repair gum tissue loss in a patient with a history of smoking.
9. An oral and maxillofacial surgeon grafting mucosal tissue onto the roots of a tooth to prepare it for orthodontic treatment.
10. A periodontist performing periodontal mucosal grafting to repair gum tissue loss in a patient with a genetic predisposition to gum disease.