2025 CPT code 41116
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Excision of a lesion from the floor of the mouth.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., 51 for multiple procedures, 52 for reduced services, 22 for increased procedural services).
Medical necessity is established through clinical evaluation demonstrating a suspicious lesion in the floor of the mouth that requires excisional biopsy for definitive diagnosis and treatment. The extent of the resection depends on the size, location and nature of the lesion, and overall patient health.
The physician performs the excision, prepares the tissue sample for pathology, and closes the incision.
In simple words: The doctor cuts out a growth in the floor of your mouth, takes a sample to test, and stitches up the area.
This procedure involves making an incision in the floor of the mouth, excising the lesion along with surrounding tissue, and sending the excised tissue for pathological analysis. The incision is then closed, with closure technique varying depending on the lesion's size and depth. Superficial lesions may not require closure.
Example 1: A patient presents with a suspicious ulcer on the floor of the mouth.The physician performs an excisional biopsy under local anesthesia, removing the lesion and surrounding tissue for histopathological examination.The wound is closed primarily with absorbable sutures., A patient presents with a small, well-defined lesion on the floor of the mouth. The physician excises the lesion under local anesthesia. The lesion is superficial and requires no closure., A patient with a larger lesion in the floor of the mouth requiring excision undergoes a procedure under general anesthesia. The excision includes a larger area of surrounding tissue for a wider margin. The surgeon closes the resulting defect with layered sutures. A drain is placed to prevent fluid accumulation and infection. Post-operative care instructions regarding oral hygiene, diet, and pain management are provided. The patient is scheduled for follow-up appointments to monitor the healing process and assess the pathology results.
* Operative report detailing the procedure, including size and location of lesion, extent of excision, and closure technique.* Pathology report confirming diagnosis and extent of resection margins.* Preoperative and postoperative clinical photographs if applicable.* Anesthesia records.* Any relevant imaging studies (e.g., MRI, CT scan).
** This code is used for the excision of lesions in the floor of the mouth. The size and depth of the lesion will influence the surgical approach and post-operative care.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- Payment Status: Active
- Specialties:Oral and Maxillofacial Surgery, Otolaryngology
- Place of Service:Office, Ambulatory Surgical Center, Hospital Outpatient Department