2025 CPT code 40700
Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral
Modifiers may be applicable. Modifier 22 may be appropriate for increased procedural services, modifier 52 for reduced services, and other modifiers for specific circumstances like assistant surgeon (80, 81, 82), distinct procedural service (59), etc.
Medical necessity for cleft lip repair is established by the functional and cosmetic impairments caused by the cleft lip. This includes difficulties with feeding, speech development, and self-esteem issues related to the facial difference. The surgery aims to improve these functions and enhance the patient's quality of life.
The surgeon performs the procedure after the patient is prepped and anesthetized.They make incisions, correct the vermilion border, and reconstruct the lip to achieve a more normal appearance and function.
In simple words: This procedure repairs a split in the upper lip (cleft lip) on one side, sometimes along with a misshapen nose. The surgeon makes cuts along the split, from the mouth to the nostril, going through all the layers of the lip. They then stitch the lip back together to close the gap and improve its shape and the shape of the nose. This helps the lip look and work better.
Surgical repair of a partial or complete cleft lip defect or nasal deformity. This procedure involves incisions along the cleft margins from mouth to nostril, through mucosa, muscle, and skin. The vermilion border is corrected, and the procedure aims to restore normal lip function and address nasal deformity. This code is for a unilateral procedure (one side only).
Example 1: A 4-month-old infant presents with a complete unilateral cleft lip and nasal deformity. The surgeon performs a primary repair of the cleft lip and corrects the associated nasal deformity using code 40700., A 5-month-old infant with a partial unilateral cleft lip undergoes surgical repair to close the lip defect. Code 40700 is used., A 3-month-old baby with a complete unilateral cleft lip and a distorted nostril on the affected side is scheduled for a one-stage repair. The surgeon will perform a cleft lip repair and correct the nasal deformity during the same procedure. This is reported using code 40700.
Documentation should include details of the cleft lip (complete or partial), the presence of any nasal deformity, the surgical technique used, and the side of the lip affected. Operative reports, pre- and postoperative photographs, and any associated medical diagnoses should also be documented.
- Specialties:Plastic Surgery, Craniofacial Surgery, Pediatric Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center