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The procedure described by CPT® Code 41017 involves the extraoral incision and drainage of an abscess, cyst, or hematoma located in the submandibular space of the floor of the mouth. This area encompasses several deep fascial spaces, including the sublingual, submental, submandibular, and masticator spaces, which are situated around the mandible, or lower jaw. The sublingual space is positioned beneath the tongue, while the submental space is found centrally beneath the chin. The submandibular space extends from the hyoid bone to the mucosal layer of the floor of the mouth, bordered anteriorly and laterally by the mandible and inferiorly by the superficial layer of deep cervical fascia. The masticator space is defined by a split in the superficial cervical fascia that encases the ramus of the mandible and associated muscles. The procedure typically employs a submandibular approach, which involves incising through the skin and subcutaneous tissue to access the submandibular space. Depending on the specific area affected, further dissection may be required to reach the sublingual, submental, or masticator spaces. The abscess, cyst, or hematoma is then exposed, opened, and drained, with any loculations or blood clots addressed as necessary. The placement of drains may also be performed to facilitate proper healing and drainage.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure is indicated for the management of conditions affecting the deep fascial spaces of the floor of the mouth, specifically when there is the presence of an abscess, cyst, or hematoma. These conditions may arise due to infections, trauma, or other pathological processes that lead to the accumulation of pus, fluid, or blood in the submandibular space or adjacent areas.
The procedure begins with a submandibular approach, where an incision is made through the skin and subcutaneous tissue to access the submandibular space. This initial dissection allows the surgeon to enter the submandibular space, where the platysma muscle is divided to facilitate further access. If the sublingual space is involved, the incision is extended through the submandibular space, and the mylohyoid muscle is divided to reach the sublingual area. In cases where the submental space is affected, dissection continues into the submental space located beneath the chin. For involvement of the masticator space, the dissection is directed along the lateral surface of the ramus of the mandible to access this area. Once the appropriate space is entered, the abscess, cyst, or hematoma is exposed, and the contents are opened and drained. Any loculations within the abscess or cyst are broken up to ensure complete drainage, and any blood clots present in the hematoma are removed. Finally, drains may be placed to facilitate ongoing drainage and promote healing.
Post-procedure care involves monitoring the surgical site for signs of infection, ensuring that drains are functioning properly, and managing any pain or discomfort the patient may experience. Patients may be advised on wound care and signs of complications to watch for, such as increased swelling, redness, or fever. Follow-up appointments may be necessary to assess healing and remove drains if applicable. The expected recovery time can vary based on the extent of the procedure and the patient's overall health.
| Short Descr | DRAINAGE OF MOUTH LESION | Medium Descr | XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMNDB | Long Descr | Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submandibular | 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 |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 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). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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 | GW | Service not related to the hospice patient's terminal condition | GX | Notice of liability issued, voluntary under payer policy | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | 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) |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| Pre-1990 | Added | Code added. |
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