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The procedure identified by CPT® Code 41115 is known as a frenectomy, specifically the excision of the lingual frenum. This surgical intervention is primarily indicated for the treatment of ankyloglossia, commonly referred to as tongue-tie, a condition where the lingual frenum, which is the tissue connecting the underside of the tongue to the floor of the mouth, is abnormally short or thick. This condition can restrict the movement of the tongue, potentially leading to difficulties in speech, feeding, and oral hygiene. During the frenectomy, the frenum is accessed through the placement of tension sutures on either side of the tongue, allowing for a clear view and access to the frenum. The excision is performed starting from the tip of the tongue and extending backward toward the mandibular lingual alveolus, which is the bony ridge in the lower jaw where the teeth are anchored. After the frenum is completely removed, the underlying mucosa of both the tongue and the floor of the mouth is carefully undermined to facilitate proper healing, and the area is then sutured to ensure closure and promote recovery.
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The procedure of excision of the lingual frenum (frenectomy) is indicated for the following conditions:
The frenectomy procedure involves several key steps to ensure effective excision of the lingual frenum:
After the frenectomy, patients may experience some discomfort and swelling in the area. Post-procedure care typically includes instructions for pain management, which may involve over-the-counter pain relievers. Patients are advised to maintain good oral hygiene to prevent infection and to follow any specific dietary recommendations to avoid irritation of the surgical site. Follow-up appointments may be scheduled to monitor healing and ensure that the tongue's mobility improves as expected.
| Short Descr | EXCISION OF TONGUE FOLD | Medium Descr | EXCISION LINGUAL FRENUM FRENECTOMY | Long Descr | Excision of lingual frenum (frenectomy) | 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 | 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) | P5E - Ambulatory procedures - other | 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. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 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.) | 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 | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | 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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