2025 CPT code 41520

Surgical revision of the frenulum (e.g., using Z-plasty).

Adhere to current CPT coding guidelines provided by the American Medical Association. Correct code selection depends on the specific surgical technique and the location of the frenulum (lingual or penile).

Modifiers may be applied based on the circumstances of the service. Consult the AMA CPT codebook and payer-specific guidelines for appropriate modifier use.

Medical necessity for 41520 is established when a restrictive frenulum demonstrably impairs function, such as breastfeeding difficulty, speech impediments, or sexual dysfunction. Documentation of these limitations and the patient's response to conservative measures should be included.

The clinical responsibility lies with the surgeon or qualified healthcare provider performing the procedure. This includes proper patient preparation, anesthesia administration (if applicable), surgical technique execution, and post-operative care instructions. The procedure necessitates careful planning and execution to avoid complications and achieve optimal functional and cosmetic outcomes.

IMPORTANT For frenotomy (simple incision), consider CPT codes 40806 or 41010.

In simple words: This code describes a surgical procedure to fix a problem with a small band of tissue.In the mouth, this band connects the tongue to the bottom of the mouth. In the penis, it connects the foreskin to the head. The surgery uses special stitches to reshape the tissue, making it more flexible and allowing for better movement of the tongue or penis.

This CPT code, 41520, encompasses surgical revision of the frenulum, a small band of tissue connecting the tongue to the floor of the mouth or the foreskin to the glans penis.The procedure corrects a deformity in the frenulum using techniques other than simple incision or complete excision.Methods like Z-plasty, which involves rearranging tissues with a Z-shaped incision, are included. The goal is to improve the range of motion of the tongue or the foreskin.This code is distinct from frenotomy (simple incision) or frenectomy (complete excision).

Example 1: A 3-year-old child with ankyloglossia (tongue-tie) exhibiting difficulty breastfeeding and speech impairment undergoes a lingual frenuloplasty using Z-plasty. This corrects the tongue's restricted movement., An adult patient presents with a tight frenulum (foreskin) causing pain during sexual intercourse and erection. The surgeon performs a frenuloplasty to correct the deformity and improve sexual function., An infant with an abnormally short lingual frenulum experiences difficulty with breastfeeding. A lingual frenuloplasty, a relatively simple procedure, is performed to enhance feeding and improve oral function.

Complete medical history, including symptoms and duration of the condition; pre-operative examination notes; operative report detailing the surgical technique, including the type of incision used (e.g., Z-plasty); post-operative notes and recovery progress; any complications encountered; and photographs (before and after) may be needed.

** Accurate documentation is crucial for appropriate reimbursement.Consider using additional codes to specify the technique employed (e.g., Z-plasty) if needed for clarity and to avoid any potential coding disputes with payers.

  • Revenue Code: P6C (MINOR PROCEDURES - OTHER)
  • RVU: The relative value units (RVUs) for CPT code 41520 vary based on geographic location, facility type (non-facility vs. facility), and the specific payer.Consult the appropriate fee schedule for accurate RVU data.
  • Global Days : The global period for 41520 is not explicitly defined in standard sources.The duration depends on the complexity of the procedure and the surgeon's practice guidelines.
  • Payment Status: Active
  • Modifier TC rule: The applicability of a Technical Component (TC) modifier depends on the context of the procedure and the individual payer's policy. Generally, a TC modifier would not be necessary for a straightforward surgical revision of the frenulum.
  • Fee Schedule : Fee schedule data for this CPT code can vary considerably depending on the geographic location, the type of facility (hospital outpatient vs. physician office), and the payer involved. To ascertain the historical fee schedules, please refer to the appropriate fee schedules from previous years.
  • Specialties:Oral and Maxillofacial Surgery, Plastic Surgery, Urology
  • Place of Service:Office, Ambulatory Surgical Center, Hospital Outpatient Department
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