Q: What are appropriate codes to report the drainage and irrigation of the masseteric, submandibular, sublingual, and submental spaces when a single incision is made?
A: You should report this procedure with CPT code 41018-Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; masticator space. The rationale for using this CPT code is the masseteric space is synonymous with the masticator space, and since the physician furnished the procedure through a single incision. In addition, this CPT code has the highest work value compared to those for incision and drainage of the other spaces.
Remember to submit your claim with detailed clinical documentation, which accurately explains the procedure as you executed it.
Approved June 2008
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