Outpatient Facility Coding Alert

Question: The surgeon documents an incision of the labial frenum for both upper and lower lip. Can I bill for this twice?

Minnesota Subscriber

Answer: The code you’re looking to report for an incision of the labial frenum, also known as a frenotomy, is 40806 (Incision of labial frenum (frenotomy)). When determining whether a code may be submitted more than once, you want to check the code’s medically unlikely edits (MUEs).

An MUE is a unit of service claim edit that explains how many units of a given code a physician may submit for on one day. MUEs can be distinguished between practitioner services, durable medical equipment (DME) supplier services, and facility outpatient services.

With respect to practitioner services, code 40806 has an MUE of 2. This means that you may bill for two units or fewer on a given date of service (DOS). Furthermore, the Centers for Medicare & Medicaid Services (CMS) offers a “rationale” for each code’s respective MUE. The rationale for an MUE of 2 for 40806 is “Anatomic Consideration.”

Since there are no left and right lips, the consideration must be reflective of clinical scenarios when the surgeon performs a frenotomy on the upper and lower lips. In these cases, you may submit 40806 twice with modifier 59 (Distinct Procedural Service) or XS (Separate Structure), depending on payer.

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