2025 CPT code 41009
(Active) Effective Date: N/A Revision Date: N/A Oral Surgery - Incision and Drainage Surgery Feed
Intraoral incision and drainage of an abscess, cyst, or hematoma in the masticator space.
Modifiers may be applicable depending on the circumstances of the procedure, such as multiple procedures (modifier 51), reduced services (modifier 52), or assistant surgeon (modifier 80).
The medical necessity for an incision and drainage procedure is established by the presence of a clinically significant abscess, cyst, or hematoma that causes symptoms such as pain, swelling, or infection.The procedure is considered medically necessary when conservative management is insufficient to resolve the condition.The documentation must support the clinical need for the procedure.
The oral and maxillofacial surgeon or dentist is responsible for performing the procedure. This involves pre-operative assessment, administering anesthesia, performing the incision and drainage, irrigating the wound, and providing post-operative care.
In simple words: The doctor makes a small cut inside your mouth to drain a pocket of pus, fluid, or blood in your jaw area.This area is near your jaw muscles and the back part of your lower jaw. After draining it, the doctor cleans the area and closes the cut.
This procedure involves a surgical incision made inside the mouth (intraoral) to access and drain an abscess, cyst, or hematoma located within the masticator space. The masticator space is the anatomical region containing the muscles of mastication, the ramus (angled part) of the mandible (lower jaw), and associated blood vessels and nerves.The procedure typically includes making an incision in the floor of the mouth, accessing the affected area, draining the accumulated fluid or pus, irrigating the area with sterile saline solution, and closing the incision.
Example 1: A patient presents with a painful swelling in the lower jaw due to an infected tooth causing a masticator space abscess. The surgeon performs an intraoral incision and drainage of the abscess, relieving the swelling and pain., A patient experiences trauma to the lower jaw resulting in a hematoma (blood collection) in the masticator space. An intraoral incision and drainage are performed to evacuate the hematoma., A patient has a chronic cyst in the masticator space that causes discomfort and swelling. An intraoral incision and drainage is performed to remove the cyst contents and prevent recurrence.
* Detailed operative report documenting the incision site (intraoral, floor of mouth), the space involved (masticator), the nature of the lesion (abscess, cyst, hematoma), and the drainage technique.* Preoperative and postoperative photographs are useful for documentation.* Any relevant imaging studies (e.g., CT scan, MRI) should be included.* Patient medical history and examination findings.
** Accurate anatomical localization is essential for correct code selection.The provider's documentation must clearly specify the location of the lesion to distinguish between similar codes (41000-41008).Consider using appropriate modifiers to reflect the complexity or extent of the procedure.
- Revenue Code: P6C (Minor Procedures - Other)
- RVU: This information is not available in the provided data.Refer to CMS guidelines or a relevant fee schedule for current RVU values.
- Global Days : The global period for this procedure is not specified in the provided information.Refer to payer-specific guidelines.
- Payment Status: Active
- Modifier TC rule: The application of a technical component (TC) modifier is not directly addressed in the provided data.Consult payer guidelines for clarification.
- Fee Schedule : The provided data does not contain historical fee schedule information.Refer to publicly available fee schedules or payer-specific information.
- Specialties:Oral and Maxillofacial Surgery, Dentistry
- Place of Service:Office, Ambulatory Surgical Center, Hospital Outpatient Department