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The procedure described by CPT® Code 41016 involves the extraoral incision and drainage of an abscess, cyst, or hematoma located in the submental area of the floor of the mouth. The submental space is situated beneath the chin, centrally located in relation to the lower jaw. This procedure is essential for addressing infections or fluid accumulations that may occur in this deep fascial space, which can lead to significant discomfort and potential complications if not treated. The submental space is one of several critical areas in the floor of the mouth, which also includes the sublingual, submandibular, and masticator spaces. Each of these areas is defined by specific anatomical boundaries and is surrounded by loose connective tissue and fat, allowing for surgical access. The approach for this procedure is typically through the submandibular space, which provides a pathway to reach the submental area effectively. The procedure involves careful dissection through the skin and subcutaneous tissue, division of the platysma muscle, and entry into the submandibular space, followed by further dissection to access the submental space. This meticulous approach ensures that the abscess, cyst, or hematoma can be adequately exposed, drained, and treated, thereby alleviating symptoms and preventing further complications.
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The procedure indicated by CPT® Code 41016 is performed for specific conditions affecting the submental space. These include:
The procedure for CPT® Code 41016 involves several critical steps to ensure effective drainage of the abscess, cyst, or hematoma. The steps are as follows:
After the procedure, patients may require monitoring for signs of infection or complications. Post-operative care typically includes instructions for wound care, pain management, and signs to watch for that may indicate complications, such as increased swelling, redness, or fever. Follow-up appointments may be necessary to assess healing and to remove any drains that were placed during the procedure. It is essential for patients to adhere to the post-operative care instructions provided by their healthcare provider to ensure optimal recovery.
| Short Descr | DRAINAGE OF MOUTH LESION | Medium Descr | XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMENT | Long Descr | Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submental | 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 | 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. | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AG | Primary physician | 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) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| Pre-1990 | Added | Code added. |
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