tci Outpatient Facility Coding Alert - 2016 Issue 1

Reader Question: Double Check Before Coding 40810 With 40820

Question: Our oral surgeon used surgical excision to remove a lesion from the vestibule of a patient’s mouth. He used a laser to control bleeding after the procedure. Can I report both 40810 and 40820 for the procedures? If so, should I include any modifiers? Delaware Subscriber Answer: You are correct in reporting 40810 (Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair) for the removal of a lesion from the vestibule of the mouth. You use this code when your surgeon performs surgical excision of the lesion without any closure. Your clinician also performed...

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