How To Use CPT Code 41018

CPT 41018 describes the procedure of extraoral incision and drainage of an abscess, cyst, or hematoma in the masticator space of the floor of the mouth. 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 41018?

CPT 41018 is used to describe the extraoral incision and drainage procedure performed by a healthcare provider to treat an abscess, cyst, or hematoma in the masticator space of the floor of the mouth. This code is specifically used when the incision is made outside the mouth to access the affected area.

2. Official Description

The official description of CPT code 41018 is: ‘Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; masticator space.’ This code should be used when the provider makes an incision in the lower border of the mandible to reach the masticator space and drains the abscess, cyst, or hematoma.

3. Procedure

1. The healthcare provider prepares the patient and administers anesthesia.
2. An extraoral incision is made in the lower border of the mandible.
3. The provider dissects the tissue near the mandibular ramus to access the masticator space.
4. The abscess, cyst, or hematoma is drained.
5. A drain may be placed at the site of incision, and the incision is sutured.

4. Qualifying circumstances

CPT 41018 is performed when a patient has an abscess, cyst, or hematoma in the masticator space of the floor of the mouth. The procedure is typically performed by a healthcare provider who is trained and qualified to perform extraoral incisions and drainage. The patient must meet the criteria for the specific condition being treated.

5. When to use CPT code 41018

CPT code 41018 should be used when the healthcare provider performs an extraoral incision and drainage procedure for an abscess, cyst, or hematoma in the masticator space of the floor of the mouth. This code is not appropriate for intraoral procedures or procedures performed in other areas of the mouth.

6. Documentation requirements

To support a claim for CPT 41018, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Details of the incision and drainage procedure
• Location of the incision and the affected area
• Any additional procedures performed, such as drain placement or suturing
• Any complications or follow-up care required
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 41018, ensure that the procedure meets the criteria for an extraoral incision and drainage of an abscess, cyst, or hematoma in the masticator space. It is important to use the correct code based on the specific location and nature of the procedure. Review the documentation requirements and ensure that all necessary information is included in the claim.

8. Historical information

CPT 41018 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 procedure to treat an abscess in the masticator space of the floor of the mouth.
2. An abscess in the masticator space of the floor of the mouth is drained by making an incision outside the mouth.
3. A patient undergoes an extraoral incision and drainage procedure for a cyst in the masticator space of the floor of the mouth.
4. A healthcare provider performs an extraoral incision and drainage procedure to treat a hematoma in the masticator space of the floor of the mouth.
5. An abscess in the masticator space of the floor of the mouth is drained by making an incision in the lower border of the mandible.
6. A patient undergoes an extraoral incision and drainage procedure for a cyst in the masticator space of the floor of the mouth.
7. A healthcare provider performs an extraoral incision and drainage procedure to treat a hematoma in the masticator space of the floor of the mouth.
8. An abscess in the masticator space of the floor of the mouth is drained by making an incision outside the mouth.
9. A patient undergoes an extraoral incision and drainage procedure for a cyst in the masticator space of the floor of the mouth.
10. A healthcare provider performs an extraoral incision and drainage procedure to treat a hematoma in the masticator space of the floor of the mouth.