Otolaryngology Coding Alert

Question: What’s the CPT^® code to report for the resection of a lesion of the buccal mucosa?

Mississippi Subscriber

Answer: Understanding the anatomy of the mouth and related terminology is important if you want to reach the correct lesion excision CPT^® code. According to Dorland’s Illustrated Medical Dictionary, the term buccal is defined as “pertaining to or directed toward the cheek.” Specifically, the buccal mucosa is the area of mucosal tissue lining the inner cheek walls.

Translating that knowledge over to the index of the CPT^® manual requires some additional know-how. There are numerous avenues that can steer you in the wrong direction, so you want to be considerate of your search term when navigating the index. For example, if you search Resection ⇒ Mouth, With Tongue Excision (Glossectomy), you’ll arrive at code 41153 (Glossectomy; composite procedure with resection floor of mouth, with suprahyoid neck dissection).

A glossectomy, or partial or complete removal of the tongue, is clearly not the procedure you’re looking for. There are multiple ways to reach the correct code set for a buccal mucosal lesion resection, but you’ve got to have one key term in mind in order to do so — vestibule. The vestibule of the mouth is comprised of the area between the teeth, lips, and cheeks. The CPT^® manual further explains in the Surgery subsection “Digestive System” that the vestibule “is the part of the oral cavity outside the dentoalveolar structures; it includes the mucosal and submucosal tissue of lips and cheeks.”

With this knowledge at your disposal, you can access the correct code set by searching for Excision ⇒ Mouth ⇒ Lesion ⇒ Mucosa/Submucosa or Vestibule of mouth ⇒ Excision ⇒ Lesion. Both avenues will lead you to one of the following codes:

• 40810 (Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair)
• 40812 (… with simple repair)
• 40814 (… with complex repair)
• 40816 (… complex, with excision of underlying muscle)

You’ll need to examine the operative report for documentation surrounding the repair (if any) in addition to whether the surgeon excised underlying muscle beneath the mucosal tissue. If the surgeon does perform a repair following the excision, it’s up to the physician’s discretion as to whether to classify the repair as simple or complex. There are no guidelines that elaborate on what constitutes a simple or complex repair. If the physician does not go above and beyond the scope of what’s typically included in an excision of a lesion of the submucosal tissue of the cheek, then report code 40812.