2025 CPT code 41018
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Extraoral incision and drainage of abscess, cyst, or hematoma in the floor of the mouth; masticator space.
Modifiers may be applicable depending on the circumstances.Consult the CPT modifier guidelines for appropriate modifier usage.
The procedure is medically necessary when an abscess, cyst, or hematoma in the masticator space causes significant pain, swelling, or functional impairment.Drainage is needed to resolve the infection or remove the accumulated fluid or blood, preventing potential complications like sepsis or further tissue damage. Documentation must support the diagnosis and clinical need for intervention.
The surgeon is responsible for performing the extraoral incision, dissecting to the masticator space, draining the abscess/cyst/hematoma, potentially placing a drain, and suturing the incision. Pre-operative preparation and anesthesia may be handled by other clinical personnel.
In simple words: The doctor makes a cut outside the mouth to drain a pocket of pus, fluid-filled sac, or blood clot near the jaw.
This procedure involves an extraoral incision in the floor of the mouth to drain an abscess, cyst, or hematoma located within the masticator space.The surgeon makes an incision along the lower border of the mandible, dissects the tissue near the ramus to access the masticator space, and drains the affected area. A drain may be placed, and the incision is then sutured.
Example 1: A patient presents with a painful, swollen area in the lower jaw consistent with a masticator space abscess.An extraoral incision and drainage is performed to alleviate the infection and promote healing., A patient experiences trauma to the lower jaw resulting in a hematoma within the masticator space. An extraoral incision is made to evacuate the accumulated blood., A patient has a cystic lesion in the masticator space that requires drainage. An extraoral approach is deemed necessary due to the lesion's size and location.
* Thorough preoperative history and physical examination documenting the location, size, and nature of the abscess/cyst/hematoma.* Operative report detailing the incision site, surgical technique, and amount of drainage obtained.* Postoperative photographs documenting the incision and any drainage.* Pathology report if tissue samples were obtained.* Documentation supporting the medical necessity for the procedure.
** For frenoplasty, use code 41520.Always verify the location of the lesion to select the most appropriate code from the series 41015-41018.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- RVU: Data not available in source.
- Global Days : Data not available in source.
- Payment Status: Active
- Modifier TC rule: Data not available in source.
- Fee Schedule : Data not available in source.
- Specialties:Oral and Maxillofacial Surgery, Dentistry
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)