Oral Surgery Coding & Reimbursement Alert

Reader Questions:

Trouble Discerning Between 40804 vs. 40805? Use These Tips

Published on Mon May 25, 2015

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Question: Our surgeon recently removed a foreign body from the vestibule of the mouth. When I checked the options for reporting the procedure, I saw there were two, one code for simple and other complicated. I am not too sure about when to report simple and when to opt for complicated. Can you help clarify on this?

Illinois Subscriber

Answer: Before you choose on the two options that you have for removal of a foreign body from the vestibule of the mouth, you should first know whether or not to report a foreign body removal code. In order to qualify for a foreign body removal, your surgeon should have removed a foreign body through an incision and not by probing or using a tweezer to grasp the foreign body. If no incision was made to approach the foreign body, you cannot report a foreign body removal code. In such a case, you will only have to report an appropriate E/M code to include the procedure.

As you have mentioned, you have two options to report a foreign body removal:

40804 (Removal of embedded foreign body, vestibule of mouth; simple)

40805 (…complicated).

You can choose from these two codes to report a foreign body removal depending on the depth at which the foreign body was located and on the time taken by your clinician to perform the removal. If the foreign body was located more superficially and your clinician could easily approach it for removal, you report a simple code.

If the foreign body was more deeply embedded or was in close proximity to vital structures and your surgeon had to take sufficient amount of time to locate and remove the foreign body then you report 40805.

You can also base your code choice on the type of closure that your clinician performed after the procedure. If no closure was done or if the closure was simple, then you can choose 40804. If your surgeon had to perform a layered closure, then you are justified in choosing 40805.

Reimbursement: The 2015 relative value units (RVUs) for 40804 are 6.17, while 40805 carries 9.43 RVUs. This translates to a Medicare reimbursement of $220.61 for 40804 and $337.17 for 40805. You will lose out on about $110 if you are wrongly choosing 40804 instead of 40805. If in doubt, query your clinician to check if the procedure can be reported with 40804 or 40805