How To Use CPT Code 41007

CPT 41007 describes the intraoral incision and drainage of an abscess, cyst, or hematoma in the submental space, which is located under the chin. 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 41007?

CPT 41007 is used to describe the procedure of making an incision inside the mouth to reach the submental space under the chin. This procedure is performed to drain an abscess, cyst, or hematoma in that area.

2. Official Description

The official description of CPT code 41007 is: ‘Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submental space.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An intraoral incision is made to access the submental space under the chin.
3. The provider drains the abscess, cyst, or hematoma and flushes the site with saline solution.
4. Bleeding is checked and any instruments are removed.
5. Finally, any incisions are closed.

4. Qualifying circumstances

CPT 41007 is performed when there is an abscess, cyst, or hematoma in the submental space under the chin that requires drainage. The procedure is typically done by making an incision inside the mouth to access the affected area.

5. When to use CPT code 41007

CPT code 41007 should be used when the provider performs an intraoral incision and drainage of an abscess, cyst, or hematoma in the submental space under the chin. It is important to note that this code is specific to the submental space and should not be used for procedures performed in other areas of the mouth or face.

6. Documentation requirements

To support a claim for CPT 41007, the provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Details of the procedure, including the incision and drainage of the abscess, cyst, or hematoma
• Use of anesthesia, if applicable
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 41007, ensure that the procedure is performed in the submental space under the chin. It is important to review the range of codes from 41000 to 41009 to select the most appropriate code based on the specific location in the mouth. Additionally, be aware of the different codes for extraoral incision and drainage procedures in the mouth.

8. Historical information

CPT 41007 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 dentist performing an intraoral incision and drainage of an abscess in the submental space under the chin.
2. An oral surgeon draining a cyst in the submental space using an intraoral incision.
3. A maxillofacial surgeon performing an intraoral incision and drainage of a hematoma in the submental space.
4. A dental specialist performing an intraoral incision and drainage of an abscess in the submental space of a patient with an infection.
5. An oral and maxillofacial surgeon draining a cyst in the submental space of a patient with a recurring swelling.
6. A dentist performing an intraoral incision and drainage of an abscess in the submental space of a patient with a dental infection.
7. An oral surgeon draining a hematoma in the submental space of a patient who experienced trauma to the chin.
8. A maxillofacial surgeon performing an intraoral incision and drainage of a cyst in the submental space of a patient with a congenital abnormality.
9. A dental specialist draining an abscess in the submental space of a patient with a history of dental procedures.
10. An oral and maxillofacial surgeon performing an intraoral incision and drainage of a hematoma in the submental space of a patient with a bleeding disorder.