2025 ICD-10-CM code Q38.1
Ankyloglossia (tongue-tie).
Medical necessity for intervention (e.g., frenotomy or speech therapy) is established by documenting functional limitations caused by ankyloglossia, such as difficulty with breastfeeding, speech articulation problems, or impaired oral hygiene.
Diagnosis and management often involve pediatricians, otolaryngologists, oral surgeons, dentists, and speech-language pathologists.Assessment includes evaluating tongue mobility and any functional limitations related to feeding, speech, or oral hygiene.
In simple words: Tongue-tie is a condition present from birth where the tissue under the tongue is too short, making it difficult to move the tongue normally.
This code represents a congenital condition where the lingual frenulum (the tissue connecting the tongue to the floor of the mouth) is abnormally short or tight, restricting the tongue's movement.
Example 1: A newborn infant has difficulty latching onto the breast due to restricted tongue movement.Upon examination, a tight frenulum is observed, leading to a diagnosis of ankyloglossia., A toddler is referred to a speech-language pathologist due to difficulty pronouncing certain sounds.Ankyloglossia is identified as a contributing factor, and therapy is recommended to improve tongue mobility and articulation., An adult experiences difficulty with tasks such as licking an ice cream cone or playing a wind instrument due to tongue-tie diagnosed in childhood.
Documentation should include a description of the lingual frenulum's appearance (e.g., short, thick, tight), the degree of tongue mobility restriction, and any functional impact on feeding, speech, or oral hygiene.In cases where a frenotomy (surgical release of the frenulum) is performed, operative details should be documented.
** While ankyloglossia is a congenital condition, it can be diagnosed at any age. The severity of the condition and its impact on function can vary significantly among individuals.
- Payment Status: Active
- Specialties:Pediatrics, otolaryngology, oral surgery, dentistry, speech-language pathology.
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Birthing Center, Ambulatory Surgical Center, Military Treatment Facility, Federally Qualified Health Center, Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home.