2025 CPT code 42225
(Active) Effective Date: N/A Revision Date: N/A Surgery - Palatoplasty Surgery Feed
Revision palatoplasty for cleft palate; pharyngeal flap attachment.
Modifiers 22 (Increased Procedural Services), 51 (Multiple Procedures), 52 (Reduced Services), 59 (Distinct Procedural Service), and others may be applicable depending on the circumstances.
Medical necessity is established by the presence of velopharyngeal incompetence, persistent nasal regurgitation, or significant hypernasality due to an inadequate prior cleft palate repair.The procedure is medically necessary to improve speech, swallowing, and overall quality of life.
The surgeon performs the revision palatoplasty, including incising the soft palate, attaching the pharyngeal flap, closing the donor site and oral side of the soft palate, and placing nasopharyngeal airways.
In simple words: The doctor fixes a previous surgery to repair a cleft palate (opening in the roof of the mouth) using a special flap of tissue from the back of the throat. This helps close the opening between the nose and mouth, improving speech and swallowing.
This procedure involves a revision (repair) of a previous cleft palate repair, utilizing a pharyngeal flap technique.The surgeon attaches tissue from the posterior pharyngeal wall to the soft palate, creating a midline, subtotal obstruction of the oral and nasal cavities with two small lateral openings. These openings remain patent during respiration and nasal consonant production, closing during oral consonant production. The soft palate is incised in the sagittal midline from the uvula toward the junction of the soft and hard palates. The flap is sutured to the nasal side of the soft palate with interrupted sutures. The donor site is partially closed with sutures. Nasopharyngeal airways are placed through each lateral pharyngeal port for sizing and postoperative airway support. The oral side of the soft palate is then closed with interrupted sutures. This is frequently performed to correct velopharyngeal incompetence.
Example 1: A 5-year-old patient with a previous cleft palate repair that has resulted in velopharyngeal insufficiency (VPI) undergoes a revision palatoplasty with pharyngeal flap attachment to improve speech., A 10-year-old patient with a previous cleft palate repair that has resulted in persistent nasal regurgitation undergoes a revision palatoplasty with pharyngeal flap attachment to improve swallowing and speech., An adult patient with a previous cleft palate repair and hypernasality undergoes a revision palatoplasty with pharyngeal flap attachment for improved resonance and speech clarity.
* Preoperative assessment including evaluation of speech, swallowing, and nasal resonance.* Intraoperative photographs and operative notes detailing the technique used, including size and placement of the pharyngeal flap.* Postoperative assessment, including speech therapy evaluation and assessment of healing.
** This code describes a complex surgical procedure requiring significant surgical skill and expertise.Post-operative speech therapy is frequently needed.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- Payment Status: Active
- Specialties:Plastic Surgery, Oral and Maxillofacial Surgery, Otolaryngology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center