How To Use CPT Code 41005

CPT 41005 describes the procedure of intraoral incision and drainage of an abscess, cyst, or hematoma in the sublingual region, which is the area under the tongue. This article will provide an overview of CPT 41005, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 41005?

CPT 41005 is used to describe the procedure of making a superficial intraoral incision in the sublingual region to drain an abscess, cyst, or hematoma. The provider carefully performs this procedure to ensure that no deep incisions are made, which could potentially harm the surrounding structures.

2. Official Description

The official description of CPT code 41005 is: ‘Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, superficial.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. A superficial incision is made in the sublingual region, which is the area under the tongue.
3. The provider drains the abscess, cyst, or hematoma from the sublingual region.
4. The site is flushed with saline solution.
5. Bleeding is checked and any instruments are removed.
6. Any incisions in the sublingual region are closed.

4. Qualifying circumstances

CPT 41005 is performed when there is an abscess, cyst, or hematoma in the sublingual region that requires drainage. The procedure is appropriate for patients who have developed these conditions and need medical intervention. It is important for the provider to exercise caution during the procedure to avoid causing harm to the surrounding structures.

5. When to use CPT code 41005

CPT code 41005 should be used when a provider performs an intraoral incision and drainage of an abscess, cyst, or hematoma in the sublingual region. It is important to accurately document the procedure and ensure that it meets the criteria outlined in the official description.

6. Documentation requirements

To support a claim for CPT 41005, the provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Specific details of the procedure, including the location of the incision and the drainage performed
• Any complications or additional procedures performed
• Post-procedure care instructions
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 41005, it is important to ensure that the procedure meets the criteria outlined in the official description. The provider should also be aware of any specific billing guidelines or modifiers that may be required. It is important to accurately report the procedure to ensure proper reimbursement.

8. Historical information

CPT 41005 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A dentist performing an intraoral incision and drainage of an abscess in the sublingual region for a patient with a tongue abscess.
2. An oral surgeon draining a cyst in the sublingual region for a patient with a floor of mouth cyst.
3. A maxillofacial surgeon performing an intraoral incision and drainage of a hematoma in the sublingual region for a patient with a tongue hematoma.
4. An otolaryngologist draining an abscess in the sublingual region for a patient with an infected floor of mouth abscess.
5. A head and neck surgeon performing an intraoral incision and drainage of a cyst in the sublingual region for a patient with a tongue cyst.
6. A dental surgeon draining a hematoma in the sublingual region for a patient with a floor of mouth hematoma.
7. An oral and maxillofacial surgeon performing an intraoral incision and drainage of an abscess in the sublingual region for a patient with a tongue abscess.
8. A dentist draining a cyst in the sublingual region for a patient with a floor of mouth cyst.
9. An oral surgeon performing an intraoral incision and drainage of a hematoma in the sublingual region for a patient with a tongue hematoma.
10. An otolaryngologist draining an abscess in the sublingual region for a patient with an infected floor of mouth abscess.