2025 CPT code 41110
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Excision of a tongue lesion without closure.
Modifiers may apply depending on the circumstances of the service (e.g., 22 for increased procedural services, 51 for multiple procedures).
Medical necessity is established when the lesion is suspicious for malignancy or when a benign lesion causes functional impairment (e.g., difficulty speaking or eating).
The surgeon's responsibilities include prepping and anesthetizing the patient, making an elliptical incision, excising the lesion with a margin of surrounding tissue, achieving hemostasis, and potentially sending the tissue for pathological examination.
In simple words: The doctor cuts out an abnormal growth on your tongue.They might send the removed tissue to a lab for testing.
This procedure involves the surgical removal of a lesion from the tongue without subsequent closure of the wound.The provider makes an elliptical incision around the lesion, excises it along with a small margin of surrounding tissue, and may send the excised tissue for pathological analysis. Hemostasis is achieved using a combination of direct pressure and electrocautery.
Example 1: A 50-year-old presents with a suspicious ulcer on their tongue.An excision biopsy is performed under local anesthesia, and the tissue is sent to pathology for definitive diagnosis., A 10-year-old child presents with a large fibroma on the anterior tongue.Excision is performed under general anesthesia, achieving hemostasis with electrocautery., A 70-year-old patient with a history of smoking has a leukoplakia removed from the lateral border of the tongue. The lesion is excised, and the defect is left to heal by secondary intention.
Complete patient history, physical examination notes documenting the lesion's location, size, and characteristics.Operative report detailing the procedure, anesthesia used, tissue excised and sent for pathology, and hemostasis methods. Pathology report with diagnosis.
** The decision to close the wound or allow secondary intention healing depends on the size and location of the lesion and surgeon preference.Postoperative care instructions should be provided to the patient.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- Payment Status: Active
- Modifier TC rule: Not applicable. This is a complete procedure code.
- Specialties:Oral and Maxillofacial Surgery, Otolaryngology
- Place of Service:Office, Ambulatory Surgical Center, Hospital Outpatient Department