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.
Reviewed October 2023
Published June 2008
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CPT FOR ENT ARTICLES ARE A COLLABORATIVE EFFORT BETWEEN THE ACADEMY’S TEAM OF CPT ADVISORS, MEMBERS OF THE PHYSICIAN PAYMENT POLICY (3P) WORKGROUP, AND HEALTH POLICY STAFF. ARTICLES ARE DEVELOPED TO ADDRESS COMMON CODING QUESTIONS RECEIVED BY THE HEALTH POLICY TEAM, AS WELL AS TO CLARIFY CODING CHANGES AND CORRECT CODING PRINCIPLES FOR FREQUENTLY REPORTED ENT PROCEDURES. THESE ARTICLES ARE NOT INTENDED AS LEGAL, MEDICAL, OR BUSINESS ADVICE AND ARE NOT A GUARANTEE OF REIMBURSEMENT. THE INFORMATION IS ALSO NOT MEANT TO SERVE AS THE DEFINITIVE OR SOLE AUTHORITY ON BILLING AND CODING ISSUES. THE APPLICABILITY OF AAO-HNS BILLING AND CODING GUIDANCE FOR A PARTICULAR PROCEDURE, MUST BE DETERMINED BY THE RESPONSIBLE PHYSICIAN IN LIGHT OF ALL THE CIRCUMSTANCES PRESENTED BY THE INDIVIDUAL PATIENT. YOU SHOULD CONSULT WITH YOUR OWN ADVISORS AS WELL AS MEDICARE OR PRIVATE CARRIERS IN MAKING ANY DECISIONS ABOUT HOW TO BILL AND CODE PARTICULAR SERVICES OR PROCEDURES.
