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2025 CPT code 40806

Incision of the labial frenum (frenotomy).

Refer to the most recent CPT manual for coding guidelines.

Modifiers may apply depending on the circumstances of the procedure. For example, modifier 25 may be added if a significant and separately identifiable E/M service is also performed on the same day.Refer to the CPT manual for a comprehensive list of modifiers and their appropriate usage.

Medical necessity is established when a tight or short frenulum interferes with a normal function, such as breastfeeding, speech, or sexual activity.Documentation should clearly demonstrate the impact of the frenulum and the expected improvement from the procedure.

The provider performs the incision and release of the labial frenulum.Pre-operative preparation and anesthesia are also part of the clinical responsibility.

IMPORTANT May be used with an E/M code (with modifier 25 if the E/M is significant and separately identifiable).

In simple words: The doctor makes a small cut in the thin piece of tissue connecting the lip to the gum to release tightness. This helps with problems like breastfeeding difficulties or speech problems.

This procedure involves a surgical incision of a tight or short labial frenum, a small fold of tissue connecting the lip to the gum.The incision releases the tension but does not remove the frenum. It's commonly performed to alleviate issues caused by a restricted frenum, such as difficulty with breastfeeding in infants or speech impediments. The procedure is typically performed under local anesthesia.

Example 1: A newborn infant has difficulty breastfeeding due to a tight lingual frenulum (tongue-tie). A frenotomy is performed to improve latch and feeding., A child presents with a speech impediment related to a short maxillary labial frenum.A frenotomy is performed to release the restriction and improve speech., An adult experiences discomfort and bleeding during sexual activity caused by a tight frenulum. Frenotomy is performed to alleviate these symptoms.

* Pre-operative assessment of the frenulum and its impact on function.* Intraoperative documentation including description of the incision and release technique.* Postoperative assessment and plan for recovery.* Any relevant patient history, including previous treatments.

** The term "frenotomy" can refer to procedures on different locations (e.g., tongue, penis, lip).Ensure that the documentation and coding accurately reflect the specific anatomical location of the procedure.This code is specifically for the labial frenum.

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