Summary & Overview
CPT 41115: Excision of Lingual Frenum at Base of Tongue
CPT code 41115 represents a surgical excision of the lingual frenum at the base of the tongue, a procedure used to release a restrictive frenum that can affect speech, feeding, or oral function. Nationally, this code captures a focused oral soft-tissue surgery that is relevant to otolaryngology, oral and maxillofacial surgery, and some dental surgical practices. Use of this code informs utilization and payment for minor oral surgical interventions that may be performed across ambulatory surgical centers, hospital outpatient departments, and equipped office settings.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context, typical sites of service, and payer coverage patterns. The publication summarizes benchmarks for procedural utilization and reimbursement where available, highlights policy and coding considerations affecting claim submission and adjudication, and outlines related clinical scenarios that commonly justify use of the code. Data not available in the input is noted where applicable. This summary is intended for billing specialists, practice managers, and policy analysts seeking a national-level briefing on CPT code 41115 and its role in oral soft-tissue surgical services.
Billing Code Overview
CPT code 41115 describes a surgical procedure in which the provider makes an incision at the base of the tongue and excises the frenum. This procedure is a form of oral soft-tissue surgery focused on release or removal of a restrictive lingual frenum.
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Service type: Surgical excision of lingual frenum
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Typical site of service: Ambulatory surgical center or hospital outpatient department; may also be performed in an office-based surgical setting depending on provider and patient needs.
Clinical & Coding Specifications
Clinical Context
A typical patient is an infant or young child referred by a pediatrician or speech-language pathologist for difficulty with breastfeeding, poor latch, or speech/articulation concerns due to ankyloglossia (tongue-tie). The patient undergoes preoperative evaluation in an outpatient otolaryngology, pediatric, or dental clinic where history, oral exam, and feeding assessment are documented. On the day of service, the procedure is commonly performed in an ambulatory surgery center or outpatient clinic procedure room under local anesthesia with or without mild sedation for older children; neonates often receive topical anesthetic only. The provider makes an incision at the base of the tongue and excises the lingual frenum (frenotomy/frenulectomy). Immediate post-procedure assessment includes hemostasis, feeding or suction testing, and caregiver education on wound care and potential stretching exercises. Follow-up is arranged with the referring clinician or speech therapist to monitor feeding and oral function outcomes. Typical billing reflects a minor surgical procedure with possible use of modifier 50 for bilateral procedures not applicable here, 52 for reduced services if partial release is performed, or 59 if a distinct procedural service is reported on the same date of service.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 |