41115
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.75
Facility
$133.27
Non-Facility
$255.85
Documentation Required
- Clinical documentation that ankyloglossia is present and that newborn feeding difficulties or childhood articulation problems exist (policy states procedures are medically necessary 'when newborn feeding difficulties or childhood articulation problems exist').
- Appropriate ICD-10 diagnosis coding supporting medical necessity (e.g., Q38.1 Ankyloglossia and/or P92.01 - P92.9 Feeding problems of newborn) as listed in the policy.
- Procedures and codes should meet the unspecified 'selection criteria' referenced by the policy (policy repeatedly notes CPT/HCPCS/ICD-10 codes are 'covered if selection criteria are met').
Key Coverage Criteria
- CPT codes 40806, 40819, 41010, 41115, 41520 are covered if selection criteria are met.
- HCPCS codes D7960, D7961, D7962 are covered if selection criteria are met.
- Lingual or labial frenectomy, frenotomy, or frenuloplasty medically necessary for ankyloglossia when newborn feeding difficulties or childhood articulation problems exist.
- ICD-10 P92.01 - P92.9: Feeding problems of newborn (listed as covered diagnoses when selection criteria are met).
- ICD-10 Q38.1: Ankyloglossia (listed as a covered diagnosis when selection criteria are met).
- CPT/HCPCS procedures covered if selection criteria are met: 40806 (Incision of labial frenum (frenotomy)), 40819 (Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy)), 41010 (Incision of lingual frenum (frenotomy)), 41115 (Excision of lingual frenum (frenectomy)), 41520 (Frenoplasty (surgical revision of frenum, e.g., with Z-plasty) [Lingual frenuloplasty]); HCPCS D7960, D7961, D7962 when selection criteria are met.
1 Active Policy
AETNA-CPB-0116 — Frenectomy or Frenotomy for Ankyloglossia
Related Codes
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