2025 CPT code 42000
Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
Drainage of abscess of palate, uvula
Modifiers may be applicable to this code to indicate specific circumstances of the procedure. Commonly used modifiers might include those for increased procedural services, reduced services, or assistant surgeon.
Medical necessity for this procedure is established by the presence of a symptomatic abscess requiring drainage to resolve the infection and prevent complications. The documentation should clearly support the diagnosis and the need for intervention.
The physician performs the incision and drainage of the abscess under local anesthesia, ensures proper wound care, and prescribes necessary post-operative medications like analgesics and antibiotics.
In simple words: The doctor will make a small cut to drain the infection in the roof of your mouth or the dangling tissue at the back of your throat. You will get numbing medicine so you don't feel pain. The cut will be left open to heal properly. You may also receive antibiotics and pain relievers afterward.
This procedure involves draining a pus collection (abscess) located in the palate (roof of the mouth) or uvula (the tissue hanging at the back of the throat). Under local anesthesia, an incision is made over the infected area to drain the pus. The wound is left open to heal, and pain medication and antibiotics are typically prescribed post-procedure.
Example 1: A patient presents with a painful, fluctuant swelling on the soft palate consistent with an abscess. Code 42000 is used for the incision and drainage performed., A patient with an infected uvula causing difficulty swallowing undergoes incision and drainage of the uvula abscess. This procedure is coded as 42000., Following a tonsillectomy, a patient develops a peritonsillar abscess near the palate. Incision and drainage of this abscess is performed and reported with 42000.
Documentation should include the location of the abscess (palate or uvula), the size and characteristics of the abscess, the type of anesthesia used, the method of drainage, and any post-operative instructions or prescriptions.
- Specialties:Otolaryngology, Oral Surgery, Maxillofacial Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center