Excision of Benign Lesion - CDT Code Guide
Overview
CDT code D7411 pertains to the excision of a benign lesion greater than 1.25 cm within the oral cavity. This procedure is typically performed by an oral surgeon and involves the surgical removal of non-cancerous growths that exceed 1.25 cm in size. These lesions can occur on the soft tissues of the mouth, such as the gums, cheeks, or lips. The procedure is crucial for preventing potential complications or discomfort associated with larger benign lesions. It is often performed in a clinical setting under local or general anesthesia, depending on the lesion's size and location. This code is essential for accurately documenting and billing for the surgical removal of significant benign lesions in the oral and maxillofacial region.
When to Use This Code
- When a benign lesion in the oral cavity exceeds 1.25 cm in size
- In cases where the lesion causes discomfort or interferes with oral functions
- When biopsy results confirm the lesion is benign but requires removal for patient comfort
- For lesions that have shown growth over time, necessitating surgical intervention
- When a benign lesion poses a risk of infection or other complications
Documentation Requirements
- Detailed patient history and clinical examination notes
- Size and location of the lesion, confirmed through imaging or clinical assessment
- Pathology report confirming the lesion's benign nature
- Pre-operative and post-operative care instructions
- Anesthesia type and dosage used during the procedure
- Patient consent forms and documentation of any complications
Billing Considerations
When billing for D7411, ensure that the lesion size is documented as greater than 1.25 cm. This code may be subject to frequency limitations based on the patient's insurance plan. Common modifiers include those indicating bilateral procedures or additional complexity. Verify with the patient's insurance for coverage specifics, as some plans may require pre-authorization for surgical excisions.
Related CDT Codes
Frequently Asked Questions
The lesion must be benign and greater than 1.25 cm in size, as confirmed by clinical assessment or imaging.
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