2025 CPT code 41005
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, superficial
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.
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.
- Revenue Code: P5E - AMBULATORY PROCEDURES - OTHER
- Specialties:Oral Surgery, Maxillofacial Surgery, Otolaryngology, Dentistry
- Place of Service:Office, On Campus-Outpatient Hospital,Ambulatory Surgical Center