How To Use CPT Code 41130

CPT 41130 describes the surgical procedure known as hemiglossectomy, which involves the removal of one side of the tongue. 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 41130?

CPT 41130 is used to describe the surgical procedure called hemiglossectomy. This procedure involves the removal of one side of the tongue, typically performed to treat cancer of the tongue. During the surgery, the provider excises the diseased lateral half of the patient’s tongue and cauterizes any bleeding tissue. The excised area is then sutured.

2. Official Description

The official description of CPT code 41130 is: ‘Glossectomy; hemiglossectomy.’

3. Procedure

1. The patient is appropriately prepped and anesthetized for the surgery.
2. The provider makes an incision and removes the diseased lateral half of the patient’s tongue.
3. Tissue cauterization is performed as needed to control bleeding.
4. The excised area is sutured.
5. If necessary, a tracheostomy may be created to assist the patient’s breathing during and after the surgery.

4. Qualifying circumstances

Hemiglossectomy is typically performed to treat cancer of the tongue. Patients who require this procedure have a diseased lateral half of the tongue that needs to be removed. The surgery is performed by a qualified healthcare professional who has the necessary expertise in performing glossectomies.

5. When to use CPT code 41130

CPT code 41130 should be used when a provider performs a hemiglossectomy, which involves the removal of one side of the tongue. This code is appropriate for cases where the surgery is performed to treat cancer of the tongue. It should not be used for excision of less than one-half of the tongue or for other types of glossectomies.

6. Documentation requirements

To support a claim for CPT 41130, the provider must document the following information:

• Diagnosis indicating the need for hemiglossectomy
• Description of the surgical procedure performed
• Date of the surgery
• Details of any additional procedures performed, such as tracheostomy
• Any complications or unexpected findings during the surgery
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 41130, ensure that the surgery performed is a hemiglossectomy, involving the removal of one side of the tongue. It is important to provide sufficient documentation to establish medical necessity for the procedure. If a tracheostomy is performed in conjunction with the hemiglossectomy, it may be reported separately, but it is advisable to check with the payer for specific guidelines.

8. Historical information

CPT 41130 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient undergoes a hemiglossectomy to remove one side of their tongue due to cancer.
2. A provider performs a hemiglossectomy on a patient with a tumor on one side of their tongue.
3. During surgery, a provider excises the diseased lateral half of a patient’s tongue, performing a hemiglossectomy.
4. A hemiglossectomy is performed on a patient with a malignant growth on one side of their tongue.
5. A provider performs a hemiglossectomy to remove a cancerous lesion on one side of a patient’s tongue.
6. During surgery, a provider removes one side of a patient’s tongue, performing a hemiglossectomy to treat their tongue cancer.
7. A patient with cancer undergoes a hemiglossectomy to remove the diseased lateral half of their tongue.
8. A provider performs a hemiglossectomy on a patient with a tumor on one side of their tongue, excising the affected tissue.
9. During surgery, a provider removes one side of a patient’s tongue, performing a hemiglossectomy to treat their cancer.
10. A hemiglossectomy is performed on a patient with a malignant growth on one side of their tongue, removing the affected tissue.