2025 CPT code 40701

Plastic repair of cleft lip/nasal deformity; primary bilateral, 1-stage procedure.

Modifier 50 is not necessary for this code as it is inherently bilateral. Other modifiers, such as 22 (increased procedural services) may be applicable in certain complex cases.

Modifiers may be applicable depending on the specific circumstances of the procedure. Refer to current coding guidelines.

Medical necessity is established by the presence of a bilateral cleft lip and nasal deformity impacting form and function. Justification should emphasize the functional and aesthetic impairment caused by the condition.

The surgeon performs the procedure under general anesthesia, making incisions, correcting the cleft lip and nasal deformity, and ensuring symmetry of the vermilion border.

IMPORTANT For unilateral cleft lip repair or staged bilateral repair, use 40700, 40702, or other appropriate codes.

In simple words: This surgery fixes a cleft lip and nose problems on both sides in one operation. The doctor closes the lip gap, reshapes the lip, and improves the nose structure.

This procedure involves the surgical correction of a bilateral cleft lip and associated nasal deformities in a single operation. It includes repair of the full thickness of the mucosa, muscle, and skin, and correction of the vermilion border to maintain symmetry.

Example 1: A 10-week-old infant with a bilateral cleft lip and nasal deformity undergoes a one-stage repair., A teenager with a previously unrepaired bilateral cleft lip and nasal deformity has a primary surgical correction., A patient with a failed prior attempt at bilateral cleft lip repair undergoes a complex revision procedure using this code.

Documentation should include operative report detailing the extent of the cleft lip and nasal deformity, surgical technique used, and any complications encountered. Pre- and postoperative photographs may also be helpful.

  • Revenue Code: P1G
  • Global Days : Global days associated with this code may vary depending on payer policies.
  • Specialties:Plastic Surgery, Oral & Maxillofacial Surgery, Pediatric Surgery
  • Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center
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