2025 CPT code 41105
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Biopsy of tongue, posterior one-third.
Modifiers may be applicable, please refer to current CPT guidelines for appropriate usage.
Medical necessity must be established by documenting the patient's symptoms, signs, or diagnostic findings that justify the need for a tongue biopsy.The documentation must support the reason for performing the biopsy, such as a suspicious lesion, persistent pain, or abnormal findings on physical examination.
The physician prepares the patient, identifies the lesion, makes an incision in the posterior one-third of the tongue, excises the tissue sample, and sends it to pathology.Closure of the site is dependent on the extent of the lesion.
In simple words: A small tissue sample is taken from the back part of your tongue to check for any problems.
This code describes a procedure where a biopsy is taken from the posterior one-third of the tongue.The physician identifies the lesion, makes an incision, and removes a tissue sample for pathological analysis.Closure may not be required for superficial biopsies.
Example 1: A patient presents with a suspicious lesion on the back of their tongue. A biopsy is performed using code 41105 to determine if it’s cancerous., A patient has persistent pain and white patches on the posterior portion of their tongue. A biopsy, 41105, is taken to check for leukoplakia or other abnormalities., A patient with a history of smoking has a raised area on the back of the tongue. Code 41105 is used to obtain a biopsy to rule out dysplasia or malignancy.
Documentation should include the location of the biopsy, the size and description of the lesion, the method of biopsy, and any complications.The pathology report should also be included in the patient's record.
- Revenue Code: P5E - AMBULATORY PROCEDURES - OTHER
- Specialties:Otolaryngology, Oral Surgery, Maxillofacial Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center