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The CPT® Code 40806 refers to the procedure known as frenotomy, which involves the incision of the labial frenum. The labial frenum is a small fold of tissue that connects the inside of the lip to the gum. This procedure is typically performed to address issues related to the frenum, such as the presence of a foreign body that may be lodged in the area. During the frenotomy, a straight or elliptical incision is made to access the mucosa and submucosa, allowing for the identification and removal of the foreign body. The use of instruments such as a hemostat or grasping forceps is common in this procedure to facilitate the extraction. After the foreign body is removed, the incision may either be closed or left open to heal naturally through secondary intention. It is important to note that for simpler cases of incision and removal, CPT® Code 40804 should be used, while CPT® Code 40805 is designated for more complicated cases where the foreign body is deeply embedded and requires additional dissection of underlying tissues for successful removal.
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The procedure indicated by CPT® Code 40806, incision of the labial frenum (frenotomy), is typically performed in the presence of specific conditions or symptoms that necessitate intervention. These indications may include:
The frenotomy procedure, as described by CPT® Code 40806, involves several key steps that ensure effective removal of the foreign body and address any underlying issues with the frenum. The procedural steps include:
Following the frenotomy procedure, patients may require specific post-procedure care to ensure proper healing and recovery. It is important to monitor the incision site for any signs of infection or complications. Patients may be advised to maintain good oral hygiene and avoid irritating the area until it has fully healed. The expected recovery time can vary based on the individual case and the extent of the procedure performed. If the incision was left open, healing may occur naturally over time, while closed incisions may require follow-up visits to assess healing progress.
| Short Descr | INCISION OF LIP FOLD | Medium Descr | INCISION LABIAL FRENUM FRENOTOMY | Long Descr | Incision of labial frenum (frenotomy) | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 2 | CCS Clinical Classification | 32 - Other non-OR therapeutic procedures on nose, mouth and pharynx |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| Pre-1990 | Added | Code added. |
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