2025 CPT code 41115

Excision of the lingual frenum (frenectomy).

Adhere to current CPT coding guidelines and the instructions included in the CPT manual for proper code application.

Modifiers may apply depending on the circumstances of the procedure (e.g., 51 for multiple procedures, 22 for increased procedural services, 59 for distinct procedural service).Always consult the NCCI edits to ensure proper use of modifiers.

Medical necessity for a frenectomy is established when a short or tight lingual frenulum causes clinically significant impairment in breastfeeding, speech, oral hygiene, or overall oral function. The documentation must clearly demonstrate these impairments and the expected improvement from the procedure.

The surgeon or qualified healthcare professional performs the excision, and this procedure typically involves local anesthesia, meticulous incision and excision of the frenulum, and wound closure.

IMPORTANT 41010 (incision of lingual frenum) may be used if only an incision is performed, not a complete excision.

In simple words: The doctor cuts away a small piece of tissue under the tongue to improve tongue movement. This helps with speech, nursing (for babies), and eating.

This procedure involves the surgical excision of the lingual frenulum, a fold of tissue connecting the underside of the tongue to the floor of the mouth.The procedure aims to release restricted tongue movement, improving speech, breastfeeding (in infants), and overall oral function.It is performed under local anesthesia, with the frenulum being excised using a scalpel or laser, followed by closure of the incision.The procedure is also known as a frenectomy or frenulectomy.

Example 1: A 3-month-old infant presents with ankyloglossia (tongue-tie), experiencing difficulty breastfeeding.A lingual frenectomy is performed to improve latch and milk intake., A 7-year-old child exhibits impaired speech due to a short lingual frenulum, affecting pronunciation of certain sounds. A frenectomy is performed to improve speech articulation., An adult reports discomfort and limitations in tongue movement due to a tight lingual frenulum. A frenectomy is performed to alleviate the discomfort and enhance tongue mobility.

** Consider the use of lasers in certain cases.Always ensure proper documentation to support medical necessity and proper coding.

  • Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
  • RVU: This information is not provided in the source.Refer to CMS fee schedules for current RVU values.
  • Global Days : This information is not provided in the source.The global period will depend on the specific payer and local guidelines.
  • Payment Status: Active
  • Modifier TC rule: This information is not directly provided but typically does not require a TC modifier given the nature of the procedure.
  • Fee Schedule : Historical fee schedule data is not provided; refer to CMS fee schedules and payer-specific data for historical fee information.
  • Specialties:Oral and Maxillofacial Surgery, Pediatric Dentistry, Otolaryngology
  • Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)
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