Oral Surgery Coding & Reimbursement Alert

CPT® Coding Strategies:

Watch Graft and Anatomical Location to Zero in on Right Vestibuloplasty Code

Published on Tue Feb 23, 2016

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Hint: You will need to report an additional code to report the graft.

When your surgeon performs a vestibuloplasty, you will need to know what codes to report for the procedure performed. You will also need to understand how to differentiate between a simple and a complex vestibuloplasty as you risk losing hundreds of dollars if you make a wrong choice.

Background: Your oral surgeon will perform a vestibuloplasty that will involve a surgical deepening of the vestibule of the mouth by altering the attachment of soft tissues. This deepening of the oral vestibule is generally done by your surgeon when the vestibule does not have adequate height for the support of dentures or prior to the placement of implants.

Documentation: To obtain coverage for the procedure, you will need to provide proper documentation that includes the medical record that proves the medical necessity of the procedure. You will need to include the patient’s chart notes, imaging studies such as x-rays, photographs and test reports.

Some payers might need you to obtain prior authorization before your surgeon performs the procedure. Check with the payer to see if you will need to get an authorization prior to conducting the vestibuloplasty.

Choose From Five Codes Depending on Anatomical Location and Complexity

When your oral surgeon performs a vestibuloplasty, you will need to choose from one of the following five CPT^® codes:

40840 (Vestibuloplasty; anterior)
40842 (…posterior, unilateral)
40843 (…posterior, bilateral)
40844 (…entire arch)
40845 (…complex [including ridge extension, muscle repositioning])

If you look at descriptors to the vestibuloplasty codes, you will understand that these procedural codes should be used based on the anatomical location in which the procedure was performed. So, for instance, if your surgeon only performed the vestibuloplasty in the anterior region (from the area of the canine on one side of the arch to the area of the canine on the other side of the arch), then you will report the procedure with 40840. If the procedure was performed on one side of the arch from the area of the premolars to the area of the molars, then you report 40842.

Caveat: When you check the descriptors to the vestibuloplasty codes, you will notice that these codes are used for procedures performed on one of the arches, either maxillary or mandibular. If your surgeon performs the same vestibuloplasty procedure on the other arch also, you will have to report the same code twice with the modifier 59 (Distinct procedural service) appended to the second unit of the code. For instance, if your surgeon performs vestibuloplasty on the anterior region of both the maxillary and mandibular arches, you will have to report 40840 and 40840-59.

Discern When to Report 40845 in Lieu of Other Vestibuloplasty Codes

When you look at the vestibuloplaty codes, 40840-40844, you will see that these codes mention the anatomical location in which your clinician is performing the deepening of the vestibule. However, the code 40845 does not contain any mention of the anatomical location in its descriptor. This code can be used irrespective of the location in which your surgeon performed the procedure. So, you will need to know when to report this code instead of a code from the range, 40840-40844.

You will need to choose a code from the range 40840-40844 depending on the anatomical location if your surgeon performs a deepening of the vestibule by only performing incisions and repositioning the tissue with suturing. If on the other hand, if your clinician performs changes to muscle attachments or uses skin grafts to enhance the ridge, then you will have to choose 40845 irrespective of the anatomical location in which your surgeon is performing the procedure.

Coding tip: If your surgeon uses a skin graft for the extension of the ridge, then you will have to report this procedure separately in addition to reporting 40845. The notes to code 40845 says that you will need to report an appropriate code from the 15002-15005 for the surgical preparation or creation of recipient site for the skin graft procedure.

Reimbursement: Code 40845 carries a higher reimbursement when compared to the other vestibuloplasty codes. For instance, 40840 carries a total of 23.61 relative value units (RVUs) which when multiplied by the 2016 conversion factor of 35.8043 fetches a reimbursement of $845 whereas 40845 carries a total of 45.43 RVUs which will fetch a reimbursement of about $1519. So, you might stand to lose out on a whopping amount of about $675 if you fail to identify an instance when you can report 40845 instead of 40840.

Check documentation to see if the procedure that your surgeon performed is a simple tissue relocation vestibuloplasty or a complex vestibuloplasty. If you are unable to discern from documentation, check with your surgeon to see what code is appropriate for the procedure performed.

Watch CCI When Reporting More Than One Vestibuloplasty

If your surgeon performs more than one vestibuloplasty on a patient, you will need to check Correct Coding Initiative (CCI) edits to see if the procedural codes that you are reporting face any bundling.

You will face bundling edits if you report a simple vestibuloplasty with 40845. But, these edits carry the modifier indicator ‘1,’ which means that you can unbundle the codes and report them separately if you use a suitable modifier. Since the simple vestibuloplasty codes are column 2 codes in the edit bundle with 40485, you will have to use the modifier with the simple vestibuloplasty codes. The modifier that you will have to use is 59 (Distinct procedural service).

Similarly, among the simple codes, you will face bundling if you try to report any of these two codes together. The edit bundle between 40842 and 40843 and 40843 and 40844 carry the modifier ‘1,’ which means that the codes can be separately reported. You will need to append modifier 59 to 40842 and 40843 respectively as these are column 2 codes in the edit bundle.

However, the edit bundling between 40840 and 40842 and for codes 40840 and 40843 carry the modifier indicator ‘0,’ which means you cannot overcome the edits by using any modifier. So, if you encounter a scenario where you have to report 40840 and 40842, you can only report 40840. On the other hand, you can only report 40843 if you have a scenario where you are trying to report 40840 with 40843.