© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 41007 involves the intraoral incision and drainage of an abscess, cyst, or hematoma specifically located in the submental space, which is situated beneath the chin. This area is part of the deep fascial spaces surrounding the mandible, or lower jaw, and is critical for various oral and maxillofacial procedures. The submental space is centrally located, while the submandibular space extends from the hyoid bone to the mucosal layer of the floor of the mouth, bordered by the mandible and the superficial layer of deep cervical fascia. The masticator space, another relevant area, is formed by a split in the superficial cervical fascia that encases the ramus of the mandible and associated muscles. During the procedure, an incision is made in the mouth to access these spaces, allowing for the exposure and drainage of the abscess, cyst, or hematoma. The procedure may involve breaking up any compartments within the abscess or cyst and removing blood clots from the hematoma. Additionally, drains may be placed as necessary to facilitate proper healing and drainage. This code is specifically utilized when the procedure is performed on the submental space, distinguishing it from similar procedures performed in the submandibular or masticator spaces, which are coded differently.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure indicated by CPT® Code 41007 is performed for the following conditions:
The procedure for CPT® Code 41007 involves several key steps to ensure effective drainage of the abscess, cyst, or hematoma:
After the procedure, the patient may require monitoring for any signs of infection or complications. Instructions for care at the incision site will be provided, including guidelines on oral hygiene and dietary restrictions to promote healing. Follow-up appointments may be necessary to assess the healing process and to remove any drains if placed. Patients should be advised to report any unusual symptoms, such as increased pain, swelling, or fever, to their healthcare provider promptly.
| Short Descr | DRAINAGE OF MOUTH LESION | Medium Descr | INTRAORAL I&D TONGUE/FLOOR SUBMENTAL SPACE | Long Descr | Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submental space | 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 |
| 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). | 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. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.