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Thread: buccal mucosa graft

  1. #1

    Default buccal mucosa graft

    AAPC: Back to School
    I work in urology and need a little help with a new surgery code concerning a graft. The surgeon was doing a urethroplasty CPT 53410 and harvested from the patient the buccal mucosa to use during the urethroplasty. The problem is that this is new to our office and the cpt 40818 states that it is "donor" and to be used on another person. While code 40819 is not as specific and does basically cover the procedure. I was wondering if there was anyone who has seen and or coded this before and could offer some guidance.

  2. #2
    Join Date
    Apr 2007
    Appleton, WI

    Default wow, no response!

    I have only 5 years of Urology coding experience and I am coding this procedure for the first time. I was hoping there would be a response from someone about this.

    My questions - did you end up coding 53410 with 40819 and, what was the reimbursement?

    It's okay if you do not have an answer since your question was 7 years ago. Thanks for your post anyway. The codes you listed are helpful.

    Lucy Fale, CPC, CPC-H

  3. #3

    Red face urethroplasty with buccal mucosa graft

    I was looking for information on this procedure and came across this information. Hope it helps.

    First, you’ll report the urethroplasty based on your urologist’s documentation using one of the following codes:
    53410 —Urethroplasty, 1-stage reconstruction of male anterior urethra
    53415 —... transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous
    53430 -... reconstruction of female urethra
    In the past, when the surgeon performed a urethroplasty and used a graft fashioned from buccal mucosa—
    meaning the removal of the lining of the mouth to make a graft — you would report 40818 (Excision of mucosa of vestibule of mouth as donor graft ) for the graft excision.
    However, in June 2011, the American Urological Association (AUA) Coding Hotline stated that instead of using 40818 for the graft, you should now use CPT ? code 20926, ( Tissue grafts, other [eg, paratenon, fat, dermis] ) or CPT ? code 15240 ( Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth,neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less ),” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.
    Last edited by ElizabethAG; 04-11-2014 at 06:27 AM. Reason: more information found

  4. #4

    Default Urethroplasty with buccal mucosa graft

    Can someone explain the difference between CPT 15240 and 20926? Which would be the correct code for the buccal mucosal grafting?

  5. #5


    I just took over our Urology coding so I am learning as I go, but here is my two cents worth.

    I had one of these surgeries today and IMO I think the 20926 is more appropriate for a mucosal graft because the 15240 is for a full thickness skin graft and this is not skin.

    Code 20926 is for "tissue graft, other" and I consider mucosal tissue "other".

    Hope it helps!

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