Billing code 40816: Mouth lesion excisionMedicare rate & RVUs in Illinois
Excision of a vestibular mouth lesion followed by full-thickness skin graft closure, reported when the defect requires graft reconstruction rather than routine repair.
Medicare pays $394.29–$431.89 for 40816 in the office in Illinois, from Rest Of Illinois to Chicago. Which amount applies depends on the service address.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 9 sections
What 40816 covers
This service removes a lesion involving the mucosa and submucosa of the oral vestibule, the space between the lips or cheeks and the teeth or gums, and closes the resulting defect with a full-thickness skin graft. Oral and maxillofacial surgeons, otolaryngologists, and other surgeons who treat oral lesions may perform it. The operative note should identify the vestibular site, lesion excision, defect, and graft reconstruction.
Report this code when the lesion is excised and the defect is closed with a full-thickness skin graft, rather than with no repair or routine closure. Documentation should support the graft technique and the work performed. Medicare assigns a 90-day global period, including the day-before preoperative visit and 90 days of related postoperative care. When multiple procedures occur in the same session, the highest-valued procedure is paid in full and other procedures are subject to the standard 50% multiple-procedure reduction. Modifier 50 is inappropriate; assistant-at-surgery payment is restricted, and co-surgeons and team surgery are not permitted.
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
Where 40816 pays more and less in Illinois
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
4 payment localities
$394.29 to $431.89
| Payment locality | Office | Facility |
|---|---|---|
| Chicago | $431.89 | $302.66 |
| East St. Louis | $403.55 | $285.25 |
| Rest Of Illinois | $394.29 | $276.88 |
| Suburban Chicago | $429.26 | $297.19 |
How the 40816 rate is calculated
Each of 40816’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 40816
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 3.68Practice expense 8.06Malpractice 0.49
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 40816
40816 has a 90-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 40816
Mouth lesion excision
| Rule | CMS value | What it means |
|---|---|---|
| Global period | 090 | Major surgery: the day before, the day of, and 90 days after are included. |
| Multiple procedures | 2 | Standard reduction: highest-valued procedure at 100%, others at 50%. |
| Bilateral (modifier 50) | 0 | The 150% bilateral adjustment doesn’t apply. |
| Assistant at surgery (80/81/82/AS) | 1 | Not paid (statutory restriction). |
| Co-surgeons (62) | 0 | Not permitted. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 0 | Physician service: no professional/technical split. |
| Split (54/55/56) | 0.09/0.81/0.10 | Share of the payment for pre-op, the procedure itself, and post-op care. |
Global surgery period · 40816
Mouth lesion excision
90-day global period ends
Dec 30, 2026
Covers Sep 30, 2026 through Dec 30, 2026 (92 days, including the day before surgery).
Visit on Oct 31, 2026
Day 30 of the 90-day post-op period: related follow-up care is included in the surgical payment.
Pre-op dayGlobal period
What modifiers do to the payment
Modifier 51 · payment effect
With and without the modifier
40816 without 51 · national office
$408.49
Mouth lesion excision
40816-51 · Second procedure: 50%
$204.25
When this isn’t the highest-valued procedure in the session, Medicare pays 50% of its fee schedule amount (the highest is paid at 100%).
40816 compared with similar codes
Compare codes
40816 vs 40810 vs 40812 vs 40814 vs 40818: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 40810Mouth lesion excision
- Use 40810 for vestibular lesion excision without repair. 40816 describes excision followed by full-thickness skin graft closure.
- 40812Oral lesion excision
- 40812 describes lesion excision with simple repair; 40816 is distinguished by full-thickness skin graft closure.
- 40814Oral lesion excision
- 40814 describes complex repair after lesion excision. Use 40816 when the documented closure uses a full-thickness skin graft.
- 40818Oral graft harvest
- 40818 describes taking vestibular mucosa as a donor graft. 40816 describes excising a lesion and closing its defect with a full-thickness skin graft.
40816 billing questions
How does 40816 differ from 40810, 40812, and 40814?
40816 describes lesion excision with full-thickness skin graft closure. The neighboring codes distinguish excision without repair or with simple or complex repair; the operative documentation should support the closure method reported.
Is a biopsy code appropriate when the lesion is removed?
40808 describes biopsy of a vestibular mouth lesion. When the lesion is excised and the defect is reconstructed with a full-thickness skin graft, report the excision service rather than treating the work as biopsy alone.
What documentation supports reporting 40816?
Document the oral vestibule site, lesion excision, resulting defect, and use of a full-thickness skin graft for closure.
What postoperative care is included?
The 90-day global period includes the day-before preoperative visit and 90 days of related postoperative care.
Can modifier 50 or an assistant-at-surgery claim be used?
Modifier 50 is inappropriate for this code. Medicare does not pay an assistant at surgery for this service.
How are other procedures in the same session affected?
Under the standard multiple-procedure reduction, the highest-valued procedure is paid in full and other procedures are paid at 50%. Co-surgeons and team surgery are not permitted.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file lines behind this rate
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