Oral Surgery Coding & Reimbursement Alert

Reader Questions:

Opt for Unlisted Tongue Procedure Codes For Labial Ankyloglossia Incision

Question: Our surgeon recently performed an incision of labial ankyloglossia with primary closure for a pediatric patient. What code should I report for this procedure that our surgeon performed?Should I use the code 40806 or 41010?

Vermont Subscriber

Answer: The descriptor for 40806 is “Incision of labial frenum (frenotomy)” and the descriptor for 41010 is “Incision of lingual frenum (frenotomy).”

CPT® does not include a code that describes an incision of the labial ankyloglossia. In such a case, you can choose between two unlisted codes.

  • 41599 - Unlisted procedure, tongue, floor of mouth
  • 40799 - Unlisted procedure, lips.

Another option:  The primary aim of the procedure is to release the tongue tie. You may be able to use the code 41599 (Unlisted procedure, tongue, floor of mouth) after consulting with the provider.