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2025 CPT code 41000

Intraoral incision and drainage of an abscess, cyst, or hematoma of the tongue.

Adhere to the current CPT coding guidelines for incision and drainage procedures.Proper documentation is essential to select the correct code.Consider the specific location of the lesion within the tongue or floor of the mouth.

Modifiers may be applicable depending on the circumstances.Consult the CPT manual and payer guidelines for appropriate modifier usage. Example: Modifier 51 (Multiple Procedures) if multiple procedures are performed on the same day. Modifier 22 (Increased Procedural Services) may be needed if extensive additional services were performed. Always consult payer guidelines.

Medical necessity is established when the patient presents with symptoms consistent with an abscess, cyst, or hematoma of the tongue that requires drainage to alleviate pain, infection, or functional impairment.Documentation should support the diagnosis and the need for intervention.

The oral surgeon or dentist performs the procedure. Responsibilities include patient preparation (including anesthesia), incision, drainage, irrigation, hemostasis (stopping bleeding), and wound closure.

IMPORTANT Codes 41005-41009 describe similar procedures in different locations in the mouth.Code 41015-41018 cover extraoral incisions and drainage.

In simple words: The doctor makes a small cut inside your mouth on your tongue to drain a pocket of pus, fluid, or blood.

This procedure involves a surgical incision made inside the mouth (intraoral) to drain an abscess, cyst, or hematoma located on the tongue.The surgeon makes the incision, drains the collected fluid or pus, flushes the area with saline, controls any bleeding, removes instruments, and closes the incision.

Example 1: A patient presents with a painful, swollen area on their tongue, diagnosed as a lingual abscess.The surgeon performs an intraoral incision and drainage to relieve the infection., A patient sustains a traumatic injury to their tongue, resulting in a hematoma. An intraoral incision and drainage is performed to evacuate the accumulated blood., A patient has a slow-growing cyst on their tongue causing discomfort and interfering with speech.The surgeon performs an intraoral incision and drainage to remove the cyst contents.

A complete and accurate operative report detailing the location, size, and contents of the lesion (abscess, cyst, or hematoma), the incision site, the method of drainage, amount of fluid removed, and any complications encountered.Preoperative and postoperative notes are also necessary.

** Accurate coding of this procedure hinges on precise documentation of the location of the lesion (lingual versus sublingual, superficial versus deep) and the approach used (intraoral).The provided information should be verified against current CPT guidelines and payer policies.

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