2025 CPT code 41015
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Extraoral incision and drainage of an abscess, cyst, or hematoma of the floor of the mouth; sublingual.
Modifiers 22 (increased procedural services), 51 (multiple procedures), 52 (reduced services), and others may be applicable depending on the circumstances of the procedure.Consult the latest CPT manual for guidance.
Medical necessity for code 41015 is established when a sublingual abscess, cyst, or hematoma causes significant pain, infection, or functional impairment that requires surgical intervention for drainage.The procedure is medically necessary to prevent complications such as sepsis or airway compromise.
The surgeon performs the extraoral incision, dissects through tissues (including suprahyoid muscles), drains the abscess/cyst/hematoma, potentially places a drain, and sutures the incision. Preoperative preparation and anesthesia are also part of the clinical responsibility.
In simple words: The doctor makes a cut outside the mouth to drain a pocket of pus, fluid-filled sac, or blood clot under the tongue.
This procedure involves an extraoral incision near the lower border of the mandible to access and drain an abscess, cyst, or hematoma in the sublingual space (under the tongue).The surgeon dissects through suprahyoid muscles to reach the affected area, performs drainage, and may place a drain and sutures the incision.
Example 1: A patient presents with a painful, swollen area under their tongue, diagnosed as a sublingual abscess. The surgeon performs an extraoral incision and drainage to alleviate the infection., A patient experiences a sublingual hematoma after trauma to the mouth. The surgeon uses code 41015 to describe the extraoral approach to drain the accumulated blood., A patient has a sublingual cyst causing discomfort and difficulty swallowing. The surgeon performs extraoral incision and drainage, followed by histopathological examination of the cystic contents.
* Preoperative and postoperative diagnosis.* Detailed description of the surgical procedure, including the location and size of the incision, the tissues dissected, and the method of drainage.* Documentation of any drains placed and their removal.* Pathological reports if applicable (for cysts or abscesses).* Anesthesia records.* Photographs of the affected area before and after the procedure (optional, but beneficial).
** This code is specific to the extraoral approach for sublingual lesions. Accurate anatomical localization and detailed procedural documentation are critical for proper coding and reimbursement.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- Payment Status: Active
- Specialties:Oral and Maxillofacial Surgery, General Surgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital Outpatient Department