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The procedure described by CPT® Code 41010 refers to the incision of the lingual frenum, commonly known as a frenotomy. The lingual frenum is a small band of tissue located in the midline of the tongue, connecting the underside of the tongue to the floor of the mouth. This anatomical structure plays a crucial role in the mobility of the tongue. A frenotomy is primarily performed to address a condition known as tongue-tie, or ankyloglossia, which occurs when the lingual frenum is abnormally short or tight, restricting the movement of the tongue. This restriction can lead to difficulties in breastfeeding, speech development, and oral hygiene. During the procedure, the physician elevates the tongue towards the roof of the mouth and makes a precise incision through the frenum, typically in a single motion that is quick and efficient. Anesthesia is generally not required for this procedure, as the incision is made swiftly, minimizing discomfort for the patient.
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The procedure of incision of the lingual frenum (frenotomy) is indicated for the following conditions:
The frenotomy procedure involves several key steps that ensure the effective treatment of tongue-tie. First, the physician positions the patient comfortably, often in a supine position, to allow for easy access to the mouth. Next, the physician gently lifts the tongue towards the roof of the mouth, which helps to expose the lingual frenum clearly. Following this, the physician uses a sterile surgical instrument to make a precise incision through the frenum. This incision is typically made parallel to the tongue and is executed in a single, swift motion, which minimizes discomfort and reduces the duration of the procedure. The entire process is usually completed in a matter of seconds, and due to the quick nature of the incision, anesthesia is often deemed unnecessary. After the incision, the physician may provide guidance on post-procedure care to ensure proper healing.
After the frenotomy, patients can generally expect a quick recovery. Since the procedure is minimally invasive and performed swiftly, most individuals experience little to no discomfort. Post-procedure care may include instructions on maintaining oral hygiene to prevent infection and promote healing. Patients are typically advised to monitor the incision site for any signs of excessive bleeding or infection. Follow-up appointments may be scheduled to assess healing and ensure that the tongue's mobility has improved. Overall, the recovery period is usually brief, allowing patients to return to normal activities shortly after the procedure.
| Short Descr | INCISION OF TONGUE FOLD | Medium Descr | INCISION LINGUAL FRENUM FRENOTOMY | Long Descr | Incision of lingual frenum (frenotomy) | Status Code | Active Code | Global Days | 010 - 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 | 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 | 1 | 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | NB | Nebulizer system, any type, fda-cleared for use with specific drug |
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| Pre-1990 | Added | Code added. |
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