Ankyloglossia
ICD-10 Q38.1 is a billable code used to indicate a diagnosis of ankyloglossia.
Ankyloglossia, commonly referred to as 'tongue-tie', is a congenital condition characterized by an abnormally short or thickened lingual frenulum, which restricts the movement of the tongue. This condition can lead to difficulties in breastfeeding, speech articulation, and oral hygiene. In infants, ankyloglossia may cause challenges in latching during breastfeeding, potentially leading to inadequate nutrition and maternal discomfort. In older children and adults, it may result in speech impediments, as the limited tongue mobility can hinder the production of certain sounds. Diagnosis is typically made through a physical examination, and treatment options may include frenotomy or frenuloplasty, surgical procedures aimed at releasing the frenulum to improve tongue mobility. Ankyloglossia can occur in isolation or as part of a syndrome involving other congenital malformations, necessitating a comprehensive evaluation for associated conditions.
Pediatric documentation should include detailed assessments of feeding difficulties, speech evaluations, and any referrals to specialists. Growth charts and developmental milestones should also be documented.
Common scenarios include infants with breastfeeding difficulties, toddlers with speech delays, and children requiring surgical intervention for ankyloglossia.
Consideration should be given to the age of the patient and the impact of ankyloglossia on feeding and speech development.
Genetic documentation should focus on family history, potential syndromic associations, and any genetic testing results that may indicate a broader genetic condition.
Scenarios may include genetic counseling for families with a history of congenital anomalies and evaluations for syndromes associated with ankyloglossia.
Genetic coders should be aware of the potential for ankyloglossia to be part of a syndrome, requiring careful documentation of all associated findings.
Performed in cases of significant ankyloglossia affecting feeding or speech.
Pre-operative assessment, consent, and post-operative follow-up notes.
Pediatric surgeons and ENT specialists may be involved in the procedure.
Common treatments for ankyloglossia include frenotomy, a minor surgical procedure to release the frenulum, and speech therapy to address any speech delays resulting from the condition.
