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The CPT® Code 41113 refers to the excision of a lesion located in the posterior one-third of the tongue, accompanied by closure of the surgical site. This procedure typically begins with the administration of a local anesthetic, which is injected around and beneath the lesion to ensure patient comfort during the operation. Following anesthesia, a surgical incision is made through the epithelium, penetrating into the underlying fibrous tissue and muscle. The incision is carefully crafted to encircle the lesion, allowing for its complete excision along with a margin of healthy tissue to ensure that no residual disease remains. After the lesion is removed, it is sent to a laboratory for pathology examination, which is separately reportable. This procedure is distinct from other related codes; for instance, CPT® Code 41110 involves the excision of a small superficial lesion without the need for closure, while CPT® Code 41112 pertains to the excision of a larger, deeper lesion in the anterior two-thirds of the tongue, which also requires suture repair. In contrast, CPT® Code 41114 describes a more complex procedure where a lesion is excised and the defect is repaired using a local tongue flap, involving the elevation and rotation of adjacent myomucosal tissue to cover the surgical site. Thus, CPT® Code 41113 is specifically designated for the excision of deeper lesions in the posterior region of the tongue, ensuring proper closure and healing of the surgical site.
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The procedure associated with CPT® Code 41113 is indicated for the excision of lesions located in the posterior one-third of the tongue. These lesions may present as abnormal growths or masses that require surgical intervention for diagnosis or treatment. The specific indications for this procedure include:
The procedure for CPT® Code 41113 involves several critical steps to ensure the effective excision of the lesion. The steps are as follows:
After the procedure associated with CPT® Code 41113, patients can expect specific post-operative care and considerations. The surgical site will require monitoring for signs of infection, such as increased redness, swelling, or discharge. Patients are typically advised to maintain good oral hygiene while avoiding any irritants that could affect the healing process. Pain management may be necessary, and the healthcare provider may prescribe analgesics to alleviate discomfort. Follow-up appointments are essential to assess healing and to discuss the pathology results from the excised lesion. Depending on the findings, further treatment or monitoring may be indicated. Overall, proper post-procedure care is crucial for optimal recovery and to ensure the best possible outcomes following the excision of the lesion.
| Short Descr | EXCISION OF TONGUE LESION | Medium Descr | EXC LESION TONGUE W/CLSR POSTERIOR ONE-THIRD | Long Descr | Excision of lesion of tongue with closure; posterior one-third | 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) | 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 | 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 |
| 47 | Anesthesia by surgeon: regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (this does not include local anesthesia.) note: modifier 47 would not be used as a modifier for the anesthesia procedures. | 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.) | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | 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 | GW | Service not related to the hospice patient's terminal condition | GZ | Item or service expected to be denied as not reasonable and necessary | 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) | 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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| Pre-1990 | Added | Code added. |
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