How to get paid for a Frenectomy / Frenulectomy

How to get paid for a Frenectomy/Frenulectomy

Estela Vargas, CRDH, CEO Remote Sourcing

Frenectomy or Frenulectomy may be a covered benefit listed on a dental plan, but it must be appropriately submitted to receive payment from the insurance provider. 

When a frenectomy is performed on the same service date as another procedure, some questions surface about whether the payers will pay the claim for the frenectomy. First, let's confirm the current dental terminology and how it affects the procedure and combine it with other treatments.

NOTE: D7960 Frenulectomy-also known as Frenectomy or Frenotomy-separate procedure, is a DELETED CODE as of 2021 and will trigger a denial if it is used on dental claim forms in 2022.

D7961 (new procedure) Buccal/Labial Frenectomy (Frenulectomy)

D7962 (new procedure) Lingual Frenectomy (Frenulectomy)

D7961 and D7962 are the codes used to report an excision of a frenum that restricts the ability to function normally. The codes vary depending on the location of the frenectomy.

D7961 and D7962 are reported when an excision of a frenum restricts the ability to function normally; between the lower lip and gum and between the upper gum and lip. Sutures are inclusive and not separate from the procedure. D7961 has no age limitations. It can be performed using several known techniques. 

D7961 and D7962 are also helpful in preventing the progression of gingival recession and interference with a prosthetic appliance. The closure of large diastemas is also treated with a Frenulectomy.

Payment for these services is most often denied if it is filed on the same day on the same claim as gingivectomies, soft tissue grafts, periodontal osseous surgery, alveoloplasty, and vestibuloplasty. Payers consider the Frenulectomy as part of those services.

To appeal, the clinical notes must support a definition as a separate procedure that requires significant skill and time to achieve a successful result. 

The narrative should document the frenum location, the pathology related to its presence, and how it interferes with normal function or oral development.  

Below is a sample of a question and a response to using the above codes:

Dear Remote Sourcing:

I completed upper extractions on a patient who required labial frenectomy the same day before upper full denture delivery. Is that considered a part of the extraction procedure, or can we be reimbursed for the frenectomy also? Dr. Smith

Remote Sourcing Answered:

Insurance may consider it integral to the extractions and may disallow it if you're in-network. They'll say you have to write it off, and the patient is not responsible.

If you billed alveoloplasty or vestibuloplasty with the extractions, it is guaranteed that the frenectomy will be considered inclusive. To appeal this denial or down coding, your clinical notes need to state why the frenectomy was necessary. You'll need to describe how it was a stand-alone procedure, which required notable effort unrelated to the extractions.

The clinical notes need to state the location of the frenum and the pathological condition that interferes with proper oral function. The appeal could read something like: "Frenectomy performed on the frenulum labii superiors to eliminate interference with the complete upper denture, fabricated for your insured, patient name, to allow the denture to seal and you are insured to chew properly. It does not include the extractions performed on ______ date of service."

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