Complete ICD-10-CM coding and documentation guide for icd-10 coding for lip tie includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Lip Tie
Use ICD-10 code Q38.0 for congenital malformations of lips, not elsewhere classified, ensuring proper documentation in clinical notes.
Additional codes that may be used with this diagnosis
Problems in relationship with spouse or partner
Use when breastfeeding difficulties are documented, such as mother-infant dyad struggling due to poor latch.
Feeding difficulties
Required if poor weight gain or failure to thrive accompanies lip tie.
The ICD-10 code for lip tie is Q38.0, which covers congenital malformations of lips, including aberrant insertion of the labial frenulum.
Documentation should include frenulum insertion site, functional impacts like feeding difficulties, and use specific classification systems.