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2025 CPT code 41016

Extraoral incision and drainage of abscess, cyst, or hematoma of the floor of the mouth; submental.

Refer to the CPT manual for detailed coding guidelines and any specific instructions related to this code.

Modifiers may be applicable depending on the circumstances. Consult the CPT manual for applicable modifiers.For example, modifier -51 (multiple procedures) may apply if other procedures are performed at the same surgical session.

Medical necessity is established by the presence of a symptomatic submental abscess, cyst, or hematoma that requires drainage to alleviate symptoms and prevent complications such as infection spread.

The surgeon performs the incision, dissection, drainage, and closure of the incision.Post-operative care may be included, depending on the complexity of the case and facility policies.

IMPORTANT Consider codes 41015-41018 for other incision and drainage procedures in the mouth area.Refer to codes 41000-41009 for intraoral incision and drainage procedures.

In simple words: The doctor makes a cut outside the mouth, under the chin, to drain a pocket of pus, fluid-filled sac, or blood clot.

This procedure involves an extraoral incision made in the submental space (under the chin) to drain an abscess, cyst, or hematoma.After appropriate preparation and anesthesia, an incision is made along the lower border of the mandible.The provider dissects through muscle to access the submental space, drains the affected area, and may place a drain and sutures the incision.

Example 1: A patient presents with a painful, swollen area under the chin, diagnosed as a submental abscess. The surgeon performs an extraoral incision and drainage., A patient has a submental hematoma following trauma to the chin.The surgeon uses code 41016 to describe the extraoral incision and drainage., A patient presents with a recurrent submental cyst requiring incision and drainage. The surgeon performs the procedure and documents the findings.

* Detailed history and physical examination documenting the location, size, and nature of the lesion (abscess, cyst, or hematoma).* Pre-operative and post-operative photographic documentation of the lesion and incision site.* Operative report specifying the location, technique, and amount of drainage obtained.* Pathology report if applicable (e.g., for tissue sent for analysis).* Any complications encountered during or after the procedure.

** This code is specific to the submental space.Incisions in other locations would require different codes. Always ensure accurate documentation to support code selection.

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