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The CPT® Code 41000 refers to the procedure of intraoral incision and drainage of an abscess, cyst, or hematoma specifically located in the tongue or the floor of the mouth, also known as the lingual region. This procedure is typically indicated when there is a collection of pus, fluid, or blood that has formed in these areas, leading to swelling, pain, or infection. The process begins with the identification of the abscess, cyst, or hematoma, which is crucial for determining the appropriate course of action. Once identified, the mucosal tissue is carefully incised to access the underlying structure. The abscess pocket, cyst, or hematoma is then opened to allow for drainage, which is essential for relieving pressure and promoting healing. During this procedure, any compartments that may have developed within the abscess pocket are disrupted to ensure complete drainage. Additionally, if there are any blood clots present in the hematoma, they are removed to facilitate proper healing. Depending on the extent of the drainage required, drains may be placed to prevent re-accumulation of fluid. It is important to note that this code is specifically used when the procedure is performed on the lingual region, while different codes are designated for procedures involving the superficial sublingual area or deeper sublingual tissues.
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The procedure described by CPT® Code 41000 is indicated for the following conditions:
The procedure for CPT® Code 41000 involves several critical steps to ensure effective drainage of the abscess, cyst, or hematoma:
Post-procedure care for patients undergoing the intraoral incision and drainage involves monitoring for signs of infection, ensuring proper oral hygiene, and managing any discomfort. Patients may be advised to follow specific dietary restrictions to avoid irritation of the surgical site. Follow-up appointments may be necessary to assess healing and remove any drains if placed. It is essential to provide patients with clear instructions regarding signs of complications, such as increased swelling, pain, or fever, which may indicate the need for further medical evaluation.
| Short Descr | DRAINAGE OF MOUTH LESION | Medium Descr | INTRAORAL I&D TONGUE/FLOOR LINGUAL | Long Descr | Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 33 - Other OR therapeutic procedures on nose, mouth and pharynx |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| Pre-1990 | Added | Code added. |
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