Outpatient Facility Coding Alert

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 control of bleeding during the procedure using a laser. You cannot report 40820 (Destruction of lesion or scar of vestibule of mouth by physical methods [e.g., laser, thermal, cryo, chemical]) for this procedure as your surgeon was controlling bleeding from the same lesion that he removed through an excision. The use of the laser to control the bleeding will be considered part of the excision and cannot be reported separately with another CPT® code. You would be justified in reporting 40820 if and only if your surgeon was destroying a separate lesion using the laser.

Also, you will face Correct Coding Initiative (CCI) edits if you are trying to report 40810 and 40820 for the same patient on the same calendar date of service. However, the modifier indicator for this bundling edit is ‘1’ which means you can overcome the edit by using a modifier such as 59 (Distinct procedural service). Append the modifier to 40810 as this is the Column 2 code in the edit bundle with 40820.

In the case you described, you will only report 40810 as your clinician removed only one lesion through surgical excision.

Coding tip: You can only report both 40810 and 40820 if more than one lesion has been removed through excision and the use of physical method such as laser. If the lesions that your surgeon is destroying share borders or are adjacent, do not report them as separate destructions.

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