How To Use CPT Code 41105

CPT 41105 describes the procedure for biopsy of the posterior one-third of the tongue. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 41105?

CPT 41105 is used to describe the biopsy procedure performed on the posterior one-third of the tongue. This code is used when the provider makes an incision in the affected tissues of the tongue and removes a sample for further analysis.

2. Official Description

The official description of CPT code 41105 is: ‘Biopsy of tongue; posterior one-third.’

3. Procedure

1. During the procedure, the provider prepares the patient and administers anesthesia.
2. Next, the provider identifies the lesion in the posterior one-third of the tongue.
3. An elliptical incision is made around the lesion to obtain a sample for biopsy.
4. The excised sample, which may include the entire lesion, is sent to pathology for further analysis.
5. The closure of the biopsy site depends on the extent of the lesion, but usually, it does not require any closure.

4. Qualifying circumstances

CPT 41105 is performed when there is a need to biopsy the posterior one-third of the tongue. This procedure is typically done to diagnose any abnormalities or lesions in this specific area. It is important to note that if the biopsy is performed on the anterior two-thirds of the tongue, CPT code 41100 should be used instead.

5. When to use CPT code 41105

CPT code 41105 should be used when the provider performs a biopsy on the posterior one-third of the tongue. It is important to accurately document the location of the biopsy to ensure proper coding and billing.

6. Documentation requirements

To support a claim for CPT 41105, the provider must document the following information:

• Reason for the biopsy and the need for further analysis
• Location of the biopsy (posterior one-third of the tongue)
• Date and time of the procedure
• Details of the procedure, including the incision and excision of the sample
• Pathology report or any additional findings

7. Billing guidelines

When billing for CPT 41105, ensure that the procedure is performed on the posterior one-third of the tongue. It is important to accurately document the location to avoid any coding errors. Additionally, it is important to note that CPT code 41105 should not be reported with other codes for lesion removal from the tongue. If the provider removes lesions instead of performing a biopsy, different codes should be used.

8. Historical information

CPT 41105 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 patient undergoes a biopsy of the posterior one-third of the tongue to investigate a suspicious lesion.
2. A provider performs a biopsy on the posterior one-third of the tongue to diagnose a patient’s oral cancer.
3. During a routine examination, a provider identifies an abnormality in the posterior one-third of the tongue and performs a biopsy for further analysis.
4. A patient presents with persistent tongue pain, and a provider performs a biopsy on the posterior one-third of the tongue to determine the cause.
5. A provider performs a biopsy on the posterior one-third of the tongue to investigate a patient’s recurring tongue ulcers.
6. After noticing a suspicious lesion in the posterior one-third of the tongue, a provider performs a biopsy to rule out oral cancer.
7. A patient with a history of tongue abnormalities undergoes a biopsy on the posterior one-third of the tongue for further evaluation.
8. A provider performs a biopsy on the posterior one-third of the tongue to investigate a patient’s persistent tongue swelling.
9. During a dental examination, a provider identifies an unusual growth in the posterior one-third of the tongue and performs a biopsy for diagnosis.
10. A patient presents with difficulty swallowing, and a provider performs a biopsy on the posterior one-third of the tongue to determine the underlying cause.