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2025 CPT code 41005

Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, superficial

Ensure proper differentiation between lingual (tongue) and sublingual (under the tongue) locations. Also, distinguish between superficial and deep sublingual incisions when selecting the appropriate code.

Modifiers may be applicable, for instance, modifier 22 for increased procedural services or modifier 52 for reduced services.

Medical necessity must be established by documenting the patient's symptoms and the clinical rationale for the procedure.The documentation must show that the abscess, cyst, or hematoma required drainage for symptom relief or to prevent complications.

The physician is responsible for prepping and anesthetizing the patient, performing the incision and drainage, irrigating the site, controlling bleeding, and closing the incision as needed.

IMPORTANT Consider codes 41000-41009 for other locations within the mouth, and 41015-41018 for extraoral procedures.

In simple words: The doctor makes a small cut under the tongue to drain a pocket of pus, fluid, or blood.The area is numbed first, and the doctor is careful not to cut too deep.

This procedure involves making a superficial intraoral incision under the tongue (sublingual region) to drain an abscess, cyst, or hematoma.The procedure typically includes prepping and anesthetizing the patient, making the incision, draining the accumulated fluid or pus, flushing the site with saline, checking for bleeding, and closing the incision if necessary. Care is taken to avoid deep incisions that could damage underlying structures.

Example 1: A patient presents with a painful, swollen area under the tongue due to a sublingual abscess.The physician performs an intraoral incision and drainage using code 41005., A patient has a fluid-filled cyst under the tongue causing discomfort. The physician drains the cyst via a superficial intraoral incision, using code 41005., Following a minor injury to the floor of the mouth, a patient develops a small hematoma under the tongue.The physician performs a superficial incision and drainage to evacuate the accumulated blood, using code 41005.

Documentation should include the location and nature of the abscess, cyst, or hematoma (e.g., size, contents), the approach used (intraoral, sublingual, superficial), and any complications encountered.

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