© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 42310 involves the drainage of an abscess located in the submaxillary or sublingual regions, which are associated with the salivary glands. Salivary gland abscesses, also known as sialadenitis, occur when there is an infection or blockage in the salivary glands, leading to the accumulation of pus. The sublingual salivary glands are situated beneath the tongue and have multiple ducts that open into the floor of the mouth. The submaxillary gland, or submandibular gland, is the second largest salivary gland and is positioned in front of the angle of the jaw, within the triangle of the neck, beneath the mandible. This gland drains into Warthin's duct, which is located in the floor of the mouth, lateral to the lingual frenum. The submandibular gland consists of superficial lobes that lie above the mylohyoid muscle and deep lobes that wrap around the posterior aspect of this muscle. The procedure for CPT® Code 42310 entails an intraoral approach to drain the abscess from either the submaxillary or sublingual glands. The process begins with the identification and protection of the Wharton duct, followed by an incision in the mucosa overlying the affected gland. The lingual nerve is carefully identified and protected during the procedure. The mylohyoid muscle is retracted to expose the sublingual gland, and if the abscess is located there, it is incised and drained. If the abscess is found in the submaxillary gland, further dissection is performed to expose the gland, which is then incised and drained. This procedure is critical for alleviating infection and restoring normal function to the affected salivary glands.
© Copyright 2025 Coding Ahead. All rights reserved.
The drainage of a submaxillary or sublingual abscess is indicated in the following situations:
The procedure for CPT® Code 42310 involves several critical steps to ensure effective drainage of the abscess:
After the drainage procedure is completed, appropriate post-procedure care is essential for recovery. Patients may be monitored for signs of infection or complications. Pain management may be provided as needed, and instructions regarding oral hygiene and care of the surgical site will be given. Follow-up appointments may be scheduled to ensure proper healing and to assess the resolution of symptoms. Additionally, any drains placed during the procedure will need to be monitored and managed according to standard postoperative protocols.
| Short Descr | DRAINAGE OF SALIVARY GLAND | Medium Descr | DRG ABSC SUBMAXILLARY/SUBLINGUAL INTRAORAL | Long Descr | Drainage of abscess; submaxillary or sublingual, intraoral | 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) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 2 | 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). | 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). | 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.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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 | RT | Right side (used to identify procedures performed on the right side of the body) |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.