Pediatric Coding Alert

Question: The physician performed what he called a lingual frenotomy. The procedure she describes isn't an excision (frenectomy) or a labial frenotomy. What is the correct code for incision of the frenulum?

Arkansas Subscriber

Answer: You're correct that you shouldn't code a pure frenectomy or frenotomy in this case; your best choice is 40806 (Incision of labial frenum [frenotomy]), which represents tongue clipping (a simple clamp and snip procedure or an incision). Code 40806 has a 0-day global period.

The pediatrician probably also completed an E/M service evaluating the patient for the need for the frenectomy. Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the appropriate E/M code.