2025 CPT code 41108
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
Biopsy of floor of mouth.
Modifiers applicable to this code include:22: Increased Procedural Services47: Anesthesia by Surgeon51: Multiple Procedures52: Reduced Services54: Surgical Care Only55: Postoperative Management Only56: Preoperative Management Only58: Staged or Related Procedure or Service by the Same Physician During the Postoperative Period59: Distinct Procedural Service73: Discontinued Outpatient Hospital/ASC Procedure Prior to Anesthesia74: Discontinued Outpatient Hospital/ASC Procedure After Anesthesia76: Repeat Procedure by Same Physician77: Repeat Procedure by Another Physician78: Unplanned Return to Operating/Procedure Room by Same Physician79: Unrelated Procedure by Same Physician During Postoperative Period99: Multiple ModifiersAnd other relevant modifiers like AQ, AR, CR, ET, GA, GC, GJ, GR, KX, PD, Q5, Q6, QJ, XE, XP, XS, and XU, each with specific criteria for usage.
Medical necessity for this procedure must be established by the presence of a lesion or abnormality in the floor of the mouth requiring tissue diagnosis.
The physician is responsible for prepping and anesthetizing the patient, identifying the lesion, performing the biopsy, and ensuring proper sample handling for pathology.
In simple words: The doctor numbs an area inside your mouth, under your tongue, and removes a small tissue sample to test it for problems.
This procedure involves an incision in the floor of the mouth to excise tissue for biopsy.After prepping and anesthetizing the patient, the provider identifies the lesion and makes an elliptical incision around it. The excised sample, potentially the entire lesion, is sent to pathology. Closure depends on the lesion's extent; superficial excisions typically require no closure.
Example 1: A patient presents with a white patch on the floor of the mouth. A biopsy is performed using code 41108 to rule out leukoplakia or other pathology., A patient with a history of smoking has a suspicious ulcer on the floor of the mouth. Code 41108 is used for the biopsy to evaluate for malignancy., During a routine oral exam, a small, raised lesion is found on the floor of the mouth. 41108 is used to obtain a biopsy for diagnostic purposes.
Documentation should include the location and description of the lesion, the method of biopsy, the size of the sample taken, and any complications encountered. The report from pathology should also be included in the patient's record.
- Revenue Code: P6C - MINOR PROCEDURES - OTHER (MEDICARE FEE SCHEDULE)
- Specialties:Oral Surgery, Otolaryngology, Dentistry
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center