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The procedure described by CPT® Code 41015 involves the extraoral incision and drainage of an abscess, cyst, or hematoma located in the floor of the mouth, specifically within the sublingual space. The sublingual space is a deep fascial area situated beneath the tongue, while the surrounding spaces, including the submental, submandibular, and masticator spaces, are also relevant to this procedure. These spaces are defined by their anatomical boundaries, with the mandible forming the anterior and lateral limits, and the superficial layer of deep cervical fascia providing the inferior boundary. The submandibular approach is utilized for accessing these spaces, which involves incising through the skin and subcutaneous tissue to reach the submandibular space. Depending on the specific area affected, further dissection may be required to enter the sublingual, submental, or masticator spaces. The procedure entails exposing the abscess, cyst, or hematoma, followed by drainage and the placement of drains if necessary. This intervention is critical for alleviating symptoms associated with these conditions and preventing complications that may arise from untreated infections or fluid collections in these anatomical regions.
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The procedure is indicated for the following conditions:
The procedure involves several key steps to ensure effective drainage of the abscess, cyst, or hematoma:
Post-procedure care involves monitoring the surgical site for signs of infection, ensuring that drains are functioning properly, and managing any pain or discomfort. Patients may be advised on oral hygiene practices to maintain cleanliness in the affected area. Follow-up appointments are typically scheduled to assess healing and to remove drains if they are no longer needed. It is important for patients to report any unusual symptoms, such as increased swelling, fever, or persistent pain, to their healthcare provider promptly.
| Short Descr | DRAINAGE OF MOUTH LESION | Medium Descr | XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBLNGL | Long Descr | Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual | 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 | Procedure or Service, Multiple Reduction Applies | 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.) | 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.) | ET | Emergency services | GC | This service has been performed in part by a resident under the direction of a teaching physician | GJ | "opt out" physician or practitioner emergency or urgent service | 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) | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 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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