2025 CPT code 41010
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Incision of the lingual frenulum (frenotomy).
Modifiers may be applicable depending on the circumstances of the procedure.For instance, modifier 51 might be used if multiple procedures are performed, or modifier 22 might be used to indicate increased procedural service.
Medical necessity is established by the presence of ankyloglossia causing significant functional impairment in areas such as feeding or speech.Documentation should include clinical findings supporting the diagnosis and the impact of the limited tongue mobility on the patient's well-being.
The clinical responsibility involves preparing the patient, administering anesthesia (if necessary), making the incision in the lingual frenulum, and potentially placing sutures (though not to close the incision). Post-operative care and assessment of the outcome are also part of the clinical responsibility.
In simple words: This procedure involves a small cut in the thin tissue under the tongue that connects the tongue to the bottom of the mouth. This is done to help people with "tongue-tie," a condition making it hard to move their tongue normally, improving breastfeeding, speech, or other issues.
A frenotomy is a surgical procedure involving an incision of the lingual frenulum, the membrane connecting the underside of the tongue to the floor of the mouth.This procedure is performed to address ankyloglossia ("tongue-tie"), a condition where the frenulum is too short or tight, restricting tongue movement. The incision frees the tongue, improving its mobility and function, often alleviating difficulties with breastfeeding or speech.The procedure may or may not involve sutures, depending on the extent of the incision and the surgeon's preference.
Example 1: A newborn infant is experiencing difficulty breastfeeding due to a tight lingual frenulum. A frenotomy is performed to release the frenulum, allowing for improved latch and feeding., A toddler presents with speech articulation problems due to restricted tongue mobility.A frenotomy is performed to improve tongue mobility and support speech therapy., An older child with a history of tongue-tie and persistent feeding problems undergoes a frenotomy to improve oral motor skills and oral hygiene.
Pre-operative assessment (including evaluation of tongue mobility and breastfeeding history), intra-operative notes detailing the incision technique and any complications, post-operative assessment of bleeding, and improvement in tongue mobility and functionality.
** This procedure is sometimes referred to as a frenulotomy or frenulectomy, all of which refer to the same clinical procedure.Variations in technique may exist depending on the age of the patient and the severity of the ankyloglossia.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- RVU: This information is not provided in the source and would require further research using a valid fee schedule database.
- Global Days : This information is not provided in the source and would require further research into relevant guidelines.
- Payment Status: Active
- Modifier TC rule: The applicability of a Technical Component (TC) modifier depends on the specific context of service provision and is not directly implied by the code description.
- Fee Schedule : Historical fee schedule information is not provided in the source but can be found in publicly available resources like the CMS fee schedules.
- Specialties:Pediatric Dentistry, Otolaryngology, Oral and Maxillofacial Surgery
- Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Ambulatory Surgical Center