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The CPT® Code 41110 refers to the excision of a lesion located on the tongue without the need for closure of the surgical site. This procedure typically involves the administration of a local anesthetic, which is injected around and beneath the lesion to ensure patient comfort during the excision. The surgeon then makes an incision that penetrates through the epithelium and into the underlying fibrous tissue and muscle. This incision is carefully crafted to encircle the lesion, allowing for its complete removal along with a margin of healthy tissue to ensure that no residual disease remains. Following the excision, the lesion is sent to a laboratory for pathology examination, which is a separate reportable service. It is important to note that this code is specifically designated for small, superficial lesions that do not require closure of the surgical site. In contrast, other related codes, such as 41112, 41113, and 41114, pertain to larger or deeper lesions that necessitate suture repair or the use of a local tongue flap for closure. This distinction is crucial for accurate coding and billing in medical practice.
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The procedure associated with CPT® Code 41110 is indicated for the excision of small, superficial lesions of the tongue. These lesions may present as growths or abnormalities that require removal for diagnostic or therapeutic purposes. The specific indications for this procedure include:
The procedure for excising a lesion of the tongue without closure involves several key steps, which are detailed as follows:
Post-procedure care for patients who have undergone the excision of a lesion of the tongue without closure typically involves monitoring for any signs of bleeding or infection at the surgical site. Patients may be advised to avoid certain foods that could irritate the area, such as spicy or acidic foods, until healing occurs. Since the surgical site is left open, it is important for patients to maintain good oral hygiene to prevent infection. Follow-up appointments may be scheduled to review pathology results and assess the healing process. Any concerns regarding pain management or unusual symptoms should be addressed promptly with the healthcare provider.
| Short Descr | EXCISION OF TONGUE LESION | Medium Descr | EXCISION LESION TONGUE W/O CLOSURE | Long Descr | Excision of lesion of tongue without closure | Status Code | Active Code | Global Days | 010 - Minor Procedure | 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) | 1 - Statutory 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 | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | 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). | 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.) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | Q0 | Investigational clinical service provided in a clinical research study that is in an approved clinical research study | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | 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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