How To Use CPT Code 41016

CPT 41016 describes the procedure for extraoral incision and drainage of an abscess, cyst, or hematoma in the submental space, which is the space under the chin. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 41016?

CPT 41016 is used to describe the extraoral incision and drainage of an abscess, cyst, or hematoma in the submental space. This procedure involves making an incision from outside the mouth into the space under the chin to drain the accumulation of pus or blood.

2. Official Description

The official description of CPT code 41016 is: ‘Extraoral incision and drainage of abscess, cyst, or hematoma of the floor of the mouth; submental.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An extraoral incision is made in the lower border of the mandible, which is the lower jaw.
3. The provider dissects the muscle to access the submental space beneath the chin.
4. The abscess, cyst, or hematoma is drained.
5. A drain may be placed at the incision site, and the incision is sutured.

4. Qualifying circumstances

CPT 41016 is performed when there is an abscess, cyst, or hematoma in the submental space that requires drainage. An abscess is a sac or pocket filled with pus, a cyst is a sac containing fluid, and a hematoma is a collection of blood outside the blood vessels. The submental space refers to the area under the chin. This procedure is typically performed by a healthcare provider who is qualified to perform incisions and drainage procedures.

5. When to use CPT code 41016

CPT code 41016 should be used when performing an extraoral incision and drainage of an abscess, cyst, or hematoma in the submental space. It is important to ensure that the procedure is performed in the specific anatomical location described by the code. If the procedure is performed in a different space in the mouth, a different CPT code should be used.

6. Documentation requirements

To support a claim for CPT 41016, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Details of the procedure, including the incision location and size
• Description of the abscess, cyst, or hematoma being drained
• Any additional procedures performed, such as drain placement or suturing
• Any complications or unexpected findings during the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 41016, ensure that the procedure is performed in the submental space as described by the code. It is important to follow the specific guidelines for reporting this procedure and to use the appropriate modifiers if necessary. Review the documentation requirements and ensure that all necessary information is included in the claim.

8. Historical information

CPT 41016 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 healthcare provider performs an extraoral incision and drainage of an abscess in the submental space for a patient with a pus-filled sac beneath their chin.
2. An abscess in the submental space of a patient requires drainage, and the provider performs an extraoral incision and drainage procedure.
3. A cyst is discovered in the submental space of a patient, and the provider performs an extraoral incision and drainage to remove the fluid-filled sac.
4. A patient presents with a hematoma in the submental space, and the provider performs an extraoral incision and drainage to relieve the collection of blood.
5. An extraoral incision and drainage procedure is performed on a patient with an abscess in the submental space, allowing for the removal of pus and resolution of the infection.
6. A healthcare provider performs an extraoral incision and drainage of a cyst in the submental space, providing relief to the patient and preventing further complications.
7. A patient with a hematoma in the submental space undergoes an extraoral incision and drainage procedure to remove the collection of blood and promote healing.
8. An abscess in the submental space of a patient requires drainage, and the provider performs an extraoral incision and drainage procedure to address the issue.
9. A cyst is discovered in the submental space of a patient, and the provider performs an extraoral incision and drainage to remove the fluid-filled sac and alleviate symptoms.
10. A patient presents with a hematoma in the submental space, and the provider performs an extraoral incision and drainage to relieve the collection of blood and promote healing.