2025 CPT code 41100
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
Biopsy of tongue; anterior two-thirds.
Modifiers can be applied to this code, including modifier 22 (Increased Procedural Services) if the procedure is significantly more complex than usual and modifier 50 (Bilateral Procedure).
Medical necessity for this procedure is established by the presence of a lesion, ulcer, or other abnormality of the anterior two-thirds of the tongue that requires diagnostic evaluation. The reason for the biopsy should be clearly documented.
The physician prepares the patient, identifies the area for biopsy, makes an incision, removes the tissue sample, and sends it to pathology.They then close the incision site as needed based on the extent of the procedure.
In simple words: A small piece of tissue is removed from the front part of your tongue to be examined for any problems.
This code describes a procedure where a biopsy is taken from the anterior two-thirds of the tongue.The physician makes an incision and removes a tissue sample for diagnostic evaluation.The complexity of the closure depends on the size and depth of the biopsy.
Example 1: A patient presents with a white patch on the anterior portion of their tongue. A biopsy is performed using code 41100 to rule out leukoplakia., A patient has a persistent ulcer on the front of their tongue.Code 41100 is used for the biopsy to check for malignancy or other pathology., An abnormality is discovered incidentally during a routine oral exam on the anterior tongue. The physician takes a biopsy (41100) to determine the nature of the tissue.
Documentation should include the location and description of the lesion, the method of biopsy, the size of the tissue sample taken, and any complications encountered. The report from the pathology lab analyzing the sample should also be included.
- Specialties:Oral Surgery, Otolaryngology, Plastic Surgery, General Surgery
- Place of Service:Office, On Campus-Outpatient Hospital,Ambulatory Surgical Center