Otolaryngology Coding Alert

Specificity is key when so many codes cover such a small anatomical area.

When it comes to a specific anatomic location such as the tongue and floor of mouth, understanding every fine detail of the operative report is crucial in determining the correct procedural code. When your provider performs an incision and drainage (I&D) of an abscess, cyst, or hematoma of this region, you've got the option of choosing between six separate codes, each identifying distinct anatomical sites within the area of the tongue and floor of mouth.

On top of that, the route of incision will also determine which set of CPT^® codes you choose from.

Read further for a full breakdown and interpretation of codes 41000 through 41017.

Know Lingual Versus Sublingual Definitions

The first set of terms to differentiate when focusing on I&D codes of the tongue or floor of mouth is lingual versus sublingual. Consider the following three CPT^® codes:

• 41000, Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual
• 41005, Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, superficial
• 41006, Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, deep, supramylohyoid.

Quite simply, a lingual incision is when the physician incises the tongue itself. A sublingual incision is when the physician incises the area below the tongue. However, "under the tongue" is a somewhat vague description, especially for medical coders who rely on the utmost degree of specificity to accurately interpret and translate operative reports into their correct corresponding codes.

Even with their basic distinctions, there is often a degree of confusion as to what the area below the tongue entails. Specifically, should you include the bottom of the tongue as part of the lingual or sublingual region?

"Lingual pertains to all aspects of the tongue," explains Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. "The sublingual area, on the other hand, consists of the extrinsic tissue located directly beneath the tongue. Any posterior element of the tongue itself should be classified as lingual," Rosenberg reiterates.

Break Sublingual into Superficial, Supramylohyoid

A proper understanding of the differences between superficial and supramylohyoid is fundamental to correctly coding I&D of the sublingual area of the mouth. You will make the decision between codes 41005 and 41006 upon examination of the location of the abscess, cyst, or hematoma and the type of incision made by the physician.

For any abscess, cyst, or hematoma that is located on the outside of the floor of the mouth (superficially), you will opt for code 41005. If the provider documents the abscess, cyst, or hematoma as "deep" or within the supramylohyoid space of the floor of the mouth, you will code the incision and drainage procedure as 41006.

Decide Between Submental, Submandibular, Masticular

The previous codes are relatively easy in the broad scheme of I&D coding of the tongue and floor of the mouth. The probability of error becomes exponentially greater when attempting to juggle the various anatomical sites within the floor of the mouth. Notice the three differentiating factors between codes 41007-41009:

• 41007, Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submental space
• 41008, Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular space
• 41009, Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; masticator space.

The submental space is, simply put, the area underneath the chin. As is a theme with this set of CPT^® codes, that's somewhat ambiguous when working with such a small, yet distinct anatomical space. However, the best way to distinguish the submental space is to differentiate it from the submandibular and masticular spaces. The submandibular area is easier to identify because it corresponds with the location of the submandibular gland, as with the sublingual space. Specifically, the submandibular space refers to the are below the lower jaw.

The masticator space, on the other hand, is the area where the masticator muscles correspond with the ramus of the lower jaw bone. A firm grasp on the sublingual (deep), submandibular, and masticular spaces allows for a coder to better identify which area "underneath the chin" the submental space belongs to. Specifically, you can identify the submental space as the area underneath the chin midline between the superior mylohyoid muscle and the inferior platysma muscle.

Key to success: While a fundamental understanding of each of these anatomical concepts is crucial, it's important that the physician properly identify these sites in the operative report of the respective procedure.

Be Sure to I.D. Intraoral, Extraoral

While less common, you should familiarize yourself with this set of extraoral I&D codes:

• 41015, Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual
• 41016, Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submental
• 41017, Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submandibular.

As is apparent, the difference between these codes and those discussed previously is the route of incision. With codes 41000-41009, the physician performs the I&D procedure via an incision within the mouth. With codes 41015-41017, on the other hand, the physician performs an incision via an external route.