How To Use CPT Code 40819

CPT 40819 describes the excision of the labial or buccal frenum, also known as frenulectomy or frenectomy. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 40819?

CPT 40819 is used to describe the excision of the labial or buccal frenum, which are membrane structures in the mouth. The procedure involves removing the frenum, including the muscle lying below it. This code is specifically used for frenectomy procedures.

2. Official Description

The official description of CPT code 40819 is: ‘Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy).’ This code is used when the provider removes the labial or buccal frenum, which restricts the motion of the lip, cheek, or tongue.

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An incision is made through the mucosa down to the muscle around the frenum.
3. The frenum, along with the underlying muscle, is excised.
4. The provider readjusts the tissues and closes the incisions.

4. Qualifying circumstances

CPT 40819 is performed on patients who have a labial or buccal frenum that restricts the motion of the lip, cheek, or tongue. This procedure is typically done to improve oral function or to prepare for other dental or orthodontic treatments. It is important to distinguish frenectomy (CPT 40819) from frenotomy (CPT 40806), which involves only an incision or clipping of the frenum.

5. When to use CPT code 40819

CPT code 40819 should be used when the provider performs a complete excision of the labial or buccal frenum. It is appropriate to use this code when the frenum removal is necessary to improve oral function or as a preparatory procedure for other dental or orthodontic treatments.

6. Documentation requirements

To support a claim for CPT 40819, the provider must document the following information:

• Patient’s diagnosis and the need for frenectomy
• Specific location of the frenum (labial or buccal)
• Date of the procedure
• Details of the procedure, including the incision, excision, and closure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 40819, ensure that the procedure performed is a complete excision of the labial or buccal frenum. It is important to distinguish frenectomy (CPT 40819) from frenotomy (CPT 40806). CPT code 40819 should not be reported with other codes for incision or clipping of the frenum. It is recommended to review the specific documentation requirements of the payer to ensure accurate billing.

8. Historical information

CPT 40819 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A dentist performing a frenectomy to improve oral function in a patient with limited lip movement.
2. An orthodontist performing a frenectomy as a preparatory procedure for orthodontic treatment in a patient with a tight labial frenum.
3. An oral surgeon performing a frenectomy to facilitate the placement of dental implants in a patient with a restrictive buccal frenum.
4. A pediatric dentist performing a frenectomy to address tongue-tie in an infant.
5. A maxillofacial surgeon performing a frenectomy to improve speech and oral function in a patient with a restrictive lingual frenum.
6. A periodontist performing a frenectomy to enhance the stability of a denture in a patient with a tight labial frenum.
7. An oral and maxillofacial surgeon performing a frenectomy to address a restrictive buccal frenum in a patient undergoing orthognathic surgery.
8. A general dentist performing a frenectomy to improve oral hygiene access in a patient with a tight labial frenum.
9. An oral and maxillofacial surgeon performing a frenectomy to facilitate the placement of a bone graft in a patient with a restrictive buccal frenum.
10. An orthodontist performing a frenectomy to address a restrictive labial frenum in a patient undergoing orthodontic treatment.