Otolaryngology Coding Alert

Question: I am struggling with the following case. What is proper coding for the diagnosis and surgery?

Diagnosis: Severe tongue tie

Procedure: Z-plasty tongue tie release

Procedure Description: The tongue was elevated, and a 2-0 black silk suture was placed through the tip of the nose for retraction. After injecting 1 percent Xylocaine with Epinephrine under the nose and in the subcutaneous tissue, I separated the nose tip from the adhesive portion usually just inside the alveolar ridge of the mandible and stretched the tongue out as much as possible.

Several z-plasties were then outlined and made along the mucosa and the frenulum of the tongue. The mucosal flaps were elevated, transposed, and sutured into place with 5-0 chromic interrupted sutures. Bleeding points under the tongue were electrocoagulated with bipolar cautery. Multiple fine interrupted sutures were placed.

Georgia Subscriber

Answer: In this case, the operative report indicates your otolaryngologist performed a repair of the frenulum by several Z-plasties. Start by looking up the term tongue in the CPT^® index and checking the subentries until you locate the term reconstruction. Below “reconstruction,” you’ll find “frenulum” and code 41520 (Frenoplasty (surgical revision of frenum, eg, with Z-plasty)).

It’s important to note that you should only report 41520. Although the physician used electrocautery on the areas of bleeding under the tongue, this was done for hemostasis and should not be coded separately.

Diagnosis roundup: The diagnosis is “severe tongue tie,” so you’ll search the ICD-10 Alphabetic Index for the term tongue, under which you’ll find “tie.” The index entry directs you to assign code Q38.1 (Ankyloglossia). When you check this code in the Tabular List, you’ll find that tongue tie is listed as a synonym.