How To Use CPT Code 41155

CPT 41155 describes a composite procedure involving the removal of the floor of the mouth, mandibular resection, and radical neck dissection (Commando type) during a glossectomy. This article will provide an overview of CPT 41155, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes.

1. What is CPT Code 41155?

CPT 41155 is a code used to describe a composite procedure that involves the removal of the floor of the mouth, mandibular resection, and radical neck dissection (Commando type) during a glossectomy. This procedure is typically performed to treat cancer and requires the provider to make both extraoral and intraoral incisions to remove the affected tissues. It also includes the removal of lymph nodes and other tissues from one side of the neck.

2. Official Description

The official description of CPT code 41155 is: ‘Glossectomy; composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection (Commando type).’ This code encompasses the comprehensive surgical removal of the tongue, floor of the mouth, mandible, and lymph nodes on one side of the neck.

3. Procedure

1. The provider begins by assessing the extent of the disease and determining the need for a glossectomy with composite procedures.
2. During the procedure, the provider removes all or part of the tongue, as well as the tissue of the floor of the mouth, using both extraoral and intraoral incisions.
3. The provider also performs a mandibular resection, removing affected tissue from the jaw bone.
4. In addition, a radical neck dissection (Commando type) is performed, involving the removal of lymph nodes and other tissues from one side of the neck.
5. The provider closes the incisions with sutures, which may include skin or mucosal grafts.
6. This procedure is most commonly used to treat cancer and may require additional reconstructive procedures, such as the placement of a metal plate or bone graft to restore the continuity of the mandible.

4. Qualifying circumstances

CPT 41155 is typically performed on patients with cancer that requires the comprehensive removal of the tongue, floor of the mouth, mandible, and lymph nodes on one side of the neck. The procedure is performed by a qualified healthcare professional who has the necessary expertise and training in performing glossectomies and composite procedures. It is important to note that this code specifically refers to the composite procedure described and should not be used for other variations of glossectomies or neck dissections.

5. When to use CPT code 41155

CPT code 41155 should be used when the provider performs a glossectomy with a composite procedure involving the resection of the floor of the mouth, mandibular resection, and radical neck dissection (Commando type). It is important to accurately document the specific procedures performed during the surgery to support the use of this code.

6. Documentation requirements

To support a claim for CPT 41155, the provider must document the following information:

• The patient’s diagnosis and the need for the glossectomy with composite procedures
• The specific procedures performed, including the resection of the floor of the mouth, mandibular resection, and radical neck dissection (Commando type)
• The date of the procedure
• Any additional reconstructive procedures performed, such as the placement of a metal plate or bone graft
• Details of the closure, including the use of sutures and any grafts
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 41155, it is important to ensure that the procedure performed aligns with the specific requirements outlined in the code description. This code should not be reported with other codes that describe different variations of glossectomies or neck dissections. It is essential to accurately document the procedures performed and provide sufficient supporting documentation to justify the use of this code.

8. Historical information

CPT code 41155 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was also added to the Inpatient Only (IPO) list for Medicare reimbursement purposes.

9. Examples

1. A patient with oral cancer undergoes a glossectomy with composite procedures, including the resection of the floor of the mouth, mandibular resection, and radical neck dissection (Commando type).
2. A provider performs a glossectomy with composite procedures on a patient with advanced tongue cancer, involving the removal of the floor of the mouth, mandible, and lymph nodes on one side of the neck.
3. During a glossectomy with composite procedures, a surgeon removes the affected tissues from the tongue, floor of the mouth, and mandible, as well as performs a radical neck dissection (Commando type) on one side of the neck.
4. A patient with extensive oral cancer undergoes a glossectomy with composite procedures, including the resection of the floor of the mouth, mandibular resection, and radical neck dissection (Commando type) to remove the diseased tissues.
5. During a glossectomy with composite procedures, a provider removes the floor of the mouth, mandible, and lymph nodes on one side of the neck to treat a patient with advanced tongue cancer.
6. A surgeon performs a glossectomy with composite procedures on a patient with oral cancer, involving the removal of the floor of the mouth, mandibular resection, and radical neck dissection (Commando type).