Barbara Posted Wed 09th of January, 2019 15:18:35 PM
Removal of papiloma floor of mouth down to the level of subcutaneous tissue lingual nerve was preserved and the papiloma was transected away from the underlying tongue musculature. I'm not comfortable coding 41116 because the tumor is not superficial, thoughts?
SuperCoder Answered Thu 10th of January, 2019 07:45:37 AM
Thank You for your Question.
CPT code 41116 states that the provider uses a scalpel and excises the lesion in the floor of the mouth along with some normal surrounding tissue and sends it to pathology for further analysis.
As per the above documentation it seems provider has excised surrounding structure of floor of mouth which is considered inclusive to the CPT code 41116.
Although if surgeon extended the excision into the floor of the mouth, as indicated by the resection of the subcutaneous tissue and surrounding mucosa, your surgeon should have dictated specifically that the excision extended into the floor of the mouth to encompass the resection of the mucosa and surrounding tissue. If your surgeon had included these details in the description, it would be correct to bill 41116 as well.
Note: If your clinician also performed an embolization along with the excision of papilloma floor of mouth, you will have to report an unlisted code for the procedure. In such a case, you will have to report the procedure with 41599 (Unlisted procedure, tongue, floor of mouth).
Hope this helps!