Summary & Overview
CPT 41108: Biopsy, Incision and Excision of Floor of Mouth Tissue
CPT code 41108 identifies a surgical biopsy procedure involving an incision in the floor of the mouth and excision of tissue for diagnostic evaluation. This code is relevant nationally for oral and maxillofacial surgeons, otolaryngologists, dental surgeons, and facilities that manage intraoral lesions. Accurate coding supports appropriate claims adjudication, clinical documentation, and capture of surgical case mix.
Key payers in national analyses include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Coverage and payment policies among these payers influence site-of-service patterns (office vs ambulatory surgery center vs hospital outpatient) and utilization tracking for head and neck lesion evaluation.
Readers will learn the clinical context of the procedure, typical sites of service, common billing modifiers in broader practice (listed separately), and where to look for related coding and policy guidance. The summary highlights benchmarks and policy considerations relevant to billing, documentation, and payer review for oral cavity biopsy procedures. Data not available in the input for specific reimbursement benchmarks, payer-specific policies, ICD-10 pairings, and associated taxonomies is noted elsewhere in the publication.
Billing Code Overview
CPT code 41108 describes an operative procedure in which the provider makes an incision in the floor of the mouth and excises tissue for the purpose of biopsy. The procedure is a minor surgical biopsy of oral floor tissue to obtain diagnostic tissue samples.
Service type: Surgical biopsy / minor oral surgery
Typical site of service: Outpatient surgical suite, ambulatory surgery center, or hospital outpatient department, and may also be performed in an office setting with appropriate surgical capability.
Clinical & Coding Specifications
Clinical Context
A 48-year-old patient presents to the oral and maxillofacial surgery clinic with a 2-week history of a small, firm, non-ulcerated mass palpable in the midline floor of mouth beneath the tongue. The lesion is clinically suspicious for neoplasm or chronic sialadenitis of a nearby minor salivary gland. After history, exam, and review of imaging (panoramic radiograph and ultrasound), the surgeon schedules a diagnostic excisional biopsy under local anesthesia with possible conversion to general anesthesia if airway or patient tolerance requires it. In the procedure room or ambulatory surgery center, the provider performs an incision in the floor of the mouth, isolates the lesion, excises the tissue down to submucosal planes, achieves hemostasis, and sends the specimen for pathology. Post-procedure, the patient is observed for airway compromise and oral bleeding, receives wound care instructions, and a pathology report follows to guide further treatment such as definitive excision if malignancy is identified.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
11 | Unusual procedural service | When significant, separately identifiable portion of service exceeds typical performance for this procedure |
22 | Increased procedural services |