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The procedure identified by CPT® Code 40819 involves the excision of the frenum, which can be either labial or buccal. This surgical intervention is commonly known by several terms, including frenumectomy, frenulectomy, or frenectomy. The frenum is a small fold of tissue that connects the lip or cheek to the gums, and in certain cases, it can lead to complications such as the displacement of dentures or interference with periodontal implant tissue. The procedure is performed to alleviate these issues by removing the frenum. During the excision, a diamond-shaped incision is typically made in the frenum to facilitate its removal. In instances where the frenum is broader, a Z-plasty type incision may be employed, which not only excises the frenum but also helps to lengthen the vestibule, thereby improving the overall oral function and aesthetics. This procedure is essential for patients experiencing discomfort or functional limitations due to an abnormal frenum attachment.
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The excision of the frenum, as described by CPT® Code 40819, is indicated in specific clinical scenarios where the frenum contributes to dental or periodontal complications. The following conditions may warrant this procedure:
The procedure for excising the frenum involves several key steps that ensure effective removal while minimizing complications. The following outlines the procedural steps:
Following the excision of the frenum, patients may experience some swelling and discomfort at the surgical site. Post-procedure care typically includes recommendations for pain management, which may involve over-the-counter analgesics. Patients are advised to maintain good oral hygiene to prevent infection and promote healing. Additionally, dietary modifications may be suggested to avoid irritation of the surgical site during the initial recovery period. Follow-up appointments may be scheduled to monitor healing and address any concerns that may arise during the recovery process.
| Short Descr | EXCISE LIP OR CHEEK FOLD | Medium Descr | EXC FRENUM LABIAL/BUCCAL | Long Descr | Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) | Status Code | Active Code | Global Days | 090 - Major Surgery | 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 | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | 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. | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | GX | Notice of liability issued, voluntary under payer policy | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| Pre-1990 | Added | Code added. |
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