Code Q38.0, congenital malformation of lips, not elsewhere classified, is the most specific code for lip tie. It would not be appropriate to report K13.0, diseases of the lips, because lip tie is a congenital anomaly. If reporting a frenotomy, report Current Procedural Terminology® code 40806, incision of labial frenum (frenotomy) for lip tie. Coders should note the differentiation between code 40806 (lip tie) and code 41010, incision of lingual frenum (frenotomy), performed to release tongue-tie.

There is no definitive answer to this question in the 1995 or 1997 E/M guidelines. However, the Documentation Guidelines for Evaluation and Management Services state that the assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The assessment of risk might include considerations such as the potential for worsening of the condition if no prescription...

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