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The CPT® Code 41006 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, particularly in the sublingual region that is deep and supramylohyoid. This procedure is performed when there is a need to address an accumulation of pus, fluid, or blood that has formed in these areas, which can lead to significant discomfort and potential complications if left untreated. The process begins with the identification of the abscess, cyst, or hematoma, followed by an incision through the mucosal tissue to access the affected area. Once the abscess pocket, cyst, or hematoma is opened, the contents are drained to relieve pressure and promote healing. Additionally, any compartments that may have developed within the abscess pocket are disrupted to ensure complete drainage. In cases of hematoma, any blood clots present are also removed to facilitate proper healing. Depending on the extent of the drainage required, drains may be placed to assist in the ongoing removal of fluid. It is important to note that this code is specifically used when deeper sublingual tissues are involved, necessitating dissection of the soft tissue that lies just above the posterior portion of the lower jaw and the hyoid bone. For procedures involving the lingual region, CPT® Code 41000 should be used, while CPT® Code 41005 is applicable for abscesses, cysts, or hematomas located in the superficial sublingual region.
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The procedure associated with CPT® Code 41006 is indicated for the following conditions:
The procedure for CPT® Code 41006 involves several critical steps to ensure effective drainage of the abscess, cyst, or hematoma:
After the procedure, patients may require specific post-operative care to ensure proper healing and to monitor for any potential complications. This may include instructions on oral hygiene, pain management, and signs of infection to watch for. Follow-up appointments may be necessary to assess the healing process and to remove any drains if placed. It is important for patients to adhere to the post-procedure care guidelines provided by their healthcare provider to promote optimal recovery.
| Short Descr | DRAINAGE OF MOUTH LESION | Medium Descr | INTRAORAL I&D TONGUE/FLOOR SUBLNGL DP SPRMLHYD | Long Descr | Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, deep, supramylohyoid | Status Code | Active Code | Global Days | 090 - Major Surgery | 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) | 0 - 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 | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 2 | CCS Clinical Classification | 33 - Other OR therapeutic procedures on nose, mouth and pharynx |
| RT | Right side (used to identify procedures performed on the right side of the body) | 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. | LT | Left side (used to identify procedures performed on the left side of the body) | 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.) | 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. | 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). | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition |
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| Pre-1990 | Added | Code added. |
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