How To Use CPT Code 41006

CPT 41006 describes the intraoral incision and drainage of an abscess, cyst, or hematoma in the sublingual or deep supramylohyoid region of the tongue or floor of the mouth. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 41006?

CPT 41006 is used to describe a procedure in which a deep intraoral incision is made in the sublingual or deep supramylohyoid region of the tongue or floor of the mouth to drain an abscess, cyst, or hematoma. This code is specifically for cases that involve the sublingual or deep supramylohyoid region.

2. Official Description

The official description of CPT code 41006 is: ‘Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, deep, supramylohyoid.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An intraoral incision is made in the sublingual or deep supramylohyoid region of the tongue or floor of the mouth.
3. The provider drains the abscess, cyst, or hematoma from the deep sublingual region.
4. The site is flushed with saline solution.
5. The provider checks for bleeding, removes any instruments, and closes any incisions.

4. Qualifying circumstances

CPT 41006 is performed when there is an abscess, cyst, or hematoma in the sublingual or deep supramylohyoid region of the tongue or floor of the mouth. The procedure is typically done to alleviate pain, prevent further complications, and promote healing. It is important to note that this code specifically applies to cases involving the sublingual or deep supramylohyoid region.

5. When to use CPT code 41006

CPT code 41006 should be used when the provider performs an intraoral incision and drainage of an abscess, cyst, or hematoma in the sublingual or deep supramylohyoid region of the tongue or floor of the mouth. It is important to ensure that the procedure is performed in the specified region to accurately report this code.

6. Documentation requirements

To support a claim for CPT 41006, the provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Specific region (sublingual or deep supramylohyoid) where the incision and drainage were performed
• Date of the procedure
• Details of the procedure, including the incision, drainage, and any additional steps taken
• Any complications or follow-up care required
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 41006, ensure that the procedure is performed in the sublingual or deep supramylohyoid region of the tongue or floor of the mouth. It is important to accurately document the specific region to support the use of this code. Review the range of codes from 41000 to 41009 to ensure the most appropriate code is selected for the specific intraoral incision and drainage procedure. Additionally, consider using codes 41015 to 41018 for extraoral incision and drainage procedures in different spaces of the mouth.

8. Historical information

CPT 41006 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A provider performs an intraoral incision and drainage of an abscess in the sublingual region of the tongue.
2. A patient presents with a cyst in the deep supramylohyoid region of the floor of the mouth, and the provider performs an intraoral incision and drainage procedure.
3. An individual has a hematoma in the sublingual region of the tongue, and the provider performs an intraoral incision and drainage to alleviate the condition.
4. A patient requires an intraoral incision and drainage of an abscess in the deep supramylohyoid region of the floor of the mouth.
5. A provider performs an intraoral incision and drainage of a cyst in the sublingual region of the tongue.
6. An individual presents with a hematoma in the deep supramylohyoid region of the floor of the mouth, and the provider performs an intraoral incision and drainage procedure.
7. A patient requires an intraoral incision and drainage of an abscess in the sublingual region of the tongue.
8. A provider performs an intraoral incision and drainage of a cyst in the deep supramylohyoid region of the floor of the mouth.
9. An individual presents with a hematoma in the sublingual region of the tongue, and the provider performs an intraoral incision and drainage to alleviate the condition.
10. A patient requires an intraoral incision and drainage of an abscess in the deep supramylohyoid region of the floor of the mouth.