Oral Surgery Coding & Reimbursement Alert

Hint: Watch CCI edits while reporting incision and excision procedures.

When your oral surgeon performs any procedures on the frenum, you’ll need to look at the exact anatomical location as you have code choices depending on this. You will also have to concentrate on whether your surgeon performed an incision or an excision.

Zero in on Identifying Anatomical Location

When your oral surgeon performs a frenum release, you’ll first have to look at which frenum your clinician operated upon. If the documentation mentions the anatomical location as labial frenum, you’ll have to report procedures related to the lip. On the other hand, if the patient notes inform you that your surgeon performed the release of the lingual frenum, you’ll have to look at options to report procedures related to the tongue. “There may also be other frenum (buccal) that are released and this should also relate to the notes in the chart to describe the anatomical areas and the functional problems as the reasons for the frenectomy,” says Barry Shipman, DMD, clinical professor, University of Florida School of Dentistry, Hialeah Dental Center.

Tip: You can also look at diagnosis to identify which of the procedural codes to report when your clinician performs the release of the frenum. If your clinician mentions the diagnosis as speech difficulties due to tongue tie, you will have to report frenum procedures related to the tongue.

Focus on Actual Surgical Procedure for Accurate Reporting

When reporting release of the frenum, after identifying the right anatomical location, you will then have to shift your attention to the actual procedure that your surgeon performed. This will help you zero in on the right code that you will have to report for the procedure performed.

If your surgeon performs a frenotomy, you will have to report the code for incision of the frenum. Based on anatomical location, you have to report these two codes when your clinician performs a frenotomy:

• 40806 (Incision of labial frenum [frenotomy])
• 41010 (Incision of lingual frenum [frenotomy])

If the patient chart notes read that your surgeon performed a frenectomy, you will have to report an excision code. Again, depending on the anatomical location, you will have to choose from one of the following two codes for an excision of the frenum:

• 40819 (Excision of frenum, labial or buccal [frenumectomy, frenulectomy, frenectomy]) 
• 41115 (Excision of lingual frenum [frenectomy])

You will have to choose the codes depending on the procedure performed. “Depending on the extent of the surgery, this is the guide to reporting the treatment. If total removal then code as removal, not as Z-plasty. If reconstructed then code as 41520 (Frenoplasty [surgical revision of frenum, e.g., with Z-plasty]),” Shipman advises.

Coding tip: Your surgeon might prefer to use different terminologies to denote excision of the frenum. Some of the common terms that all refer to an excision of the frenum includes “frenectomy,” “frenumectomy” and “frenulectomy.” You have to choose from 40819/ 41115 to report the excision irrespective of the terminology your surgeon prefers to use for the procedure.

Watch for Appropriate Diagnosis Codes to Report

When your oral surgeon performs a frenum release, it will be usually to help the patient overcome some feeding difficulties or speech disturbances caused because of the tightness of the frenum or the position in which it is attached. Along with the CPT® codes that you will report for the procedure, you will also have to report the appropriate diagnosis code to support your claim for the procedural codes.

Since there is no exact ICD-9 code to report a problem with the labial frenum, you will have to report the ICD-9 code, 744.9 (Unspecified congenital anomalies of face and neck) when your surgeon performs an incision or an excision of the labial frenum. Likewise, you will have to use 750.0 (Tongue tie) when your clinician performs a frenotomy or a frenectomy of the lingual frenum.

ICD-10 change: When you shift over to using ICD-10 codes instead of ICD-9, you will have to use Q18.9 (Congenital malformation of face and neck, unspecified) instead of 744.9 when your surgeon operates on the labial frenum. Instead of 750.0, you will have to use Q38.1 (Ankyloglossia) when your surgeon performs a surgical procedure on the labial frenum.

Don’t Report E/M Codes as a Norm

When your clinician performs a frenum release, any evaluation of the patient prior to the procedure will be considered to be part of the pre-operative evaluation and should not be reported separately using an E/M code. Also, CCI edits bundle E/M codes into the frenotomy and the frenectomy codes. So, you will face bundling issues if you report E/M codes with 40806/41010 or with 40819/41115.

However, the modifier indicator for the above mentioned code bundles is ‘1,’ which means that you can separately report the codes within the bundle by using a separate modifier. Since the E/M code is the column 2 code in the code bundle, you will have to append a modifier such as 25 (Significant,separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code.