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The procedure described by CPT® Code 41251 pertains to the repair of a laceration that measures 2.5 cm or less, specifically located in the posterior one-third of the tongue. This type of laceration repair is critical due to the unique anatomical and functional characteristics of the tongue, which plays a vital role in speech, swallowing, and overall oral health. The repair process involves several meticulous steps to ensure proper healing and functionality of the tongue post-procedure. The laceration is first irrigated to cleanse the wound, followed by debridement if necessary to remove any devitalized tissue. A layered closure technique is employed, which is essential for minimizing tension on the wound and promoting optimal healing. This involves undermining the tissues with surgical instruments to facilitate a more effective closure. Control of any bleeding is achieved through chemical means or electrocautery, ensuring that the surgical site remains stable during the repair. The closure is performed in layers, starting with the deepest layers using absorbable sutures, which are designed to dissolve over time, thus eliminating the need for suture removal. The superficial layer is then closed with careful attention to the alignment and eversion of the wound edges, which is crucial to prevent any depression of the scar that may affect the tongue's appearance and function. In cases where the laceration is deep or extends through the tongue, a more complex three-layer closure is performed, addressing the muscular mucosa first, followed by the inferior mucosa, and finally closing the superior aspect of the tongue. This detailed approach ensures that the integrity and functionality of the tongue are preserved while promoting effective healing.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure is indicated for the repair of lacerations that are 2.5 cm or less in length and specifically involve the posterior one-third of the tongue. Such lacerations may occur due to trauma, accidental injury, or other causes that compromise the integrity of the tongue's tissue.
The procedure begins with the irrigation of the laceration to cleanse the wound and remove any debris or contaminants. Following irrigation, debridement may be performed as needed to excise any non-viable tissue that could impede healing. A layered closure technique is then employed, which is critical for ensuring that the wound heals properly without excessive tension. This involves undermining the surrounding tissues using surgical scissors or a scalpel, which helps to relieve tension on the wound edges. Once the area is prepared, any bleeding is controlled using chemical agents or electrocautery to ensure a stable surgical field. The closure process starts with the deepest layers of tissue, which are secured using absorbable sutures. These sutures are designed to dissolve over time, eliminating the need for removal and minimizing patient discomfort. The knot of the sutures is buried to prevent irritation to the tongue. The next step involves closing the superficial layer of the wound, where careful attention is paid to align and evert the wound edges. This alignment is crucial to prevent any depression of the scar, which could affect the tongue's appearance and function. In cases where the laceration is deep or through-and-through, a three-layer closure is performed. This involves first closing the muscular mucosa, followed by the inferior mucosa, and finally securing the superior aspect of the tongue. This meticulous approach ensures that all layers of the tongue are properly repaired, promoting optimal healing and functionality.
Post-procedure care involves monitoring the surgical site for any signs of infection or complications. Patients may be advised to follow specific dietary restrictions to avoid irritation to the healing tissue. Pain management may be necessary, and patients should be instructed on how to care for the wound, including maintaining oral hygiene without disturbing the sutures. Follow-up appointments may be scheduled to assess healing and remove any non-absorbable sutures if used. It is important to educate patients on the signs of complications, such as increased pain, swelling, or discharge, which should prompt immediate medical attention.
| Short Descr | REPAIR TONGUE LACERATION | Medium Descr | RPR LAC 2.5 CM/< PST ONE-THIRD TONGUE | Long Descr | Repair of laceration 2.5 cm or less; posterior one-third of tongue | 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) | 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) | P5E - Ambulatory procedures - other | MUE | 2 | CCS Clinical Classification | 32 - Other non-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). | GC | This service has been performed in part by a resident under the direction of a teaching physician | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period |
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| Pre-1990 | Added | Code added. |
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