How To Use CPT Code 41010

CPT 41010 describes the procedure of incision of the lingual frenum, also known as frenotomy. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 41010?

CPT 41010 is used to describe the incision of the lingual frenum, which is a membranous ridge located under the tongue. This procedure is performed to allow greater movement of the tongue in patients with ankyloglossia, also known as tongue tie. The provider makes an incision in the lingual frenum to free it and enhance the mobility of the tongue.

2. Official Description

The official description of CPT code 41010 is: ‘Incision of lingual frenum (frenotomy).’ This procedure involves making an incision in the lingual frenum to increase the range of motion of the tongue.

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision in the lingual frenum, which is the band connecting the floor of the mouth to the alveolar ridge and the bottom of the tongue.
3. Sutures may be placed, but the incised frenum ends are not sutured together to allow increased movement of the tongue.

4. Qualifying circumstances

CPT 41010 is performed in patients with ankyloglossia, a condition in which the frenum is too short and limits the movement of the tongue. The procedure is indicated when there is a need to improve the range of motion of the tongue for functional or medical reasons.

5. When to use CPT code 41010

CPT code 41010 should be used when the provider performs an incision of the lingual frenum to increase the mobility of the tongue. It is important to note that CPT code 41010 is specifically for frenotomy, which involves only an incision or clipping of the frenum. If the provider performs excision of the frenum, CPT code 41115 should be used. Frenoplasty, which involves the reconstruction of the frenum, should be reported with CPT code 41520.

6. Documentation requirements

To support a claim for CPT 41010, the provider must document the following information:

• Patient’s diagnosis of ankyloglossia
• Procedure performed, including the incision of the lingual frenum
• Date of the procedure
• Any additional details or complications encountered during the procedure

7. Billing guidelines

When billing for CPT 41010, ensure that the procedure performed is specifically an incision of the lingual frenum. It is important to distinguish between frenotomy (CPT 41010) and frenectomy (CPT 41115). If the provider performs only an incision or clipping of the frenum, CPT code 41010 should be used. If the provider performs excision of the frenum, CPT code 41115 should be reported. Frenoplasty, which involves the reconstruction of the frenum, should be reported with CPT code 41520.

8. Historical information

CPT 41010 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A provider performs an incision of the lingual frenum to improve the range of motion of the tongue in a patient with ankyloglossia.
2. During the procedure, the provider makes a precise incision in the lingual frenum to enhance the mobility of the tongue in a patient with limited tongue movement.
3. A patient with ankyloglossia undergoes frenotomy, in which the provider makes an incision in the lingual frenum to free the tongue and improve its functionality.
4. The provider performs an incision of the lingual frenum to address the functional limitations caused by ankyloglossia in a patient.
5. In a patient with tongue tie, the provider performs frenotomy by making an incision in the lingual frenum to allow greater movement of the tongue.
6. A provider performs an incision of the lingual frenum to release the tongue and improve its range of motion in a patient with ankyloglossia.
7. During the procedure, the provider carefully makes an incision in the lingual frenum to enhance the mobility of the tongue in a patient with limited tongue movement.
8. A patient with ankyloglossia undergoes frenotomy, in which the provider makes an incision in the lingual frenum to free the tongue and improve its functionality.
9. The provider performs an incision of the lingual frenum to address the functional limitations caused by ankyloglossia in a patient.
10. In a patient with tongue tie, the provider performs frenotomy by making an incision in the lingual frenum to allow greater movement of the tongue.