tar and non cd4 1 TAR and Non-Benefit List: Codes 40000 thru 49999 Page updated: January 2021 Surgery Digestive System Note: Refer to the TAR and Non-Benefit: Introduction to List in this manual for more information about the categories of benefit restrictions. Lips Excision Code Description Benefit Restrictions 40490 Biopsy of lip Assistant Surgeon services not payable Other Procedures Code Description Benefit Restrictions 40799 Unlisted procedure, lips Requires TAR, Primary Surgeon/ Provider Vestibule of Mouth Incision Code Description Benefit Restrictions 40800 Drainage of abscess/cyst, mouth, simple Assistant Surgeon services not payable 40801 Drainage of abscess/cyst, mouth, complicated Assistant Surgeon services not payable 40804 Removal of embedded foreign body, mouth, simple Assistant Surgeon services not payable 40805 Removal of embedded foreign body, mouth, Assistant Surgeon complicated services not payable 40806 Incision labial frenum Non-Benefit Excision Code Description Benefit Restrictions 40808 Biopsy, vestibule of mouth Assistant Surgeon services not payable 40810 Excision of lesion mucosa/submucosa, mouth, without Non-Benefit repair Part 2 – TAR and Non-Benefit List: Codes 40000 thru 49999 tar and non cd4 2 Page updated: January 2021 Excision (continued) Code Description Benefit Restrictions 40812 Excision of lesion mucosa/submucosa, mouth, simple Assistant Surgeon repair services not payable 40816 Excision of lesion, mouth, mucosa/submucosa, Assistant Surgeon complex services not payable 40819 Excision of frenum, labial or buccal Assistant Surgeon services not payable 40820 Destruction of lesion/scar by physical methods Assistant Surgeon services not payable Repair Code Description Benefit Restrictions 40830 Closure of laceration, vestibule of mouth, 2.5 cm or Assistant Surgeon less services not payable Other Procedures Code Description Benefit Restrictions 40899 Unlisted procedure, vestibule of mouth Requires TAR, Primary Surgeon/ Provider Tongue, Floor of Mouth Incision Code Description Benefit Restrictions 41000 Intraoral incision and drainage of abscess; lingual Assistant Surgeon services not payable 41005 Intraoral incision and drainage of abscess; sublingual, Assistant Surgeon superficial services not payable 41007 Intraoral incision and drainage of abscess; submental Assistant Surgeon space services not payable 41008 Intraoral incision and drainage of abscess; Assistant Surgeon submandibular space services not payable 41009 Intraoral incision and drainage of abscess; masticator Assistant Surgeon space services not payable 41010 Incision lingual frenum Assistant Surgeon services not payable Part 2 – TAR and Non-Benefit List: Codes 40000 thru 49999 tar and non cd4 3 Page updated: January 2021 Incision (continued) Code Description Benefit Restrictions 41016 Extraoral incision and drainage of abscess; submental Assistant Surgeon services not payable 41017 Extraoral incision and drainage of abscess; Assistant Surgeon submandibular services not payable 41018 Extraoral incision and drainage of abscess; masticator Assistant Surgeon space services not payable Excision Code Description Benefit Restrictions 41100 Biopsy of tongue, anterior two-thirds Assistant Surgeon services not payable 41105 Biopsy of tongue, posterior one-third Assistant Surgeon services not payable 41108 Biopsy of floor of mouth Assistant Surgeon services not payable 41115 Excision of lingual frenum Non-Benefit 41116 Excision, lesion of floor of mouth Assistant Surgeon services not payable Repair Code Description Benefit Restrictions 41250 Repair of laceration, 2.5 cm or less; floor of mouth Assistant Surgeon and/or anterior two-thirds of tongue services not payable 41251 Repair of laceration, 2.