2025 CPT code 40702
(Active) Effective Date: N/A Revision Date: N/A Surgery - Repair Procedures on the Lips Surgery Feed
Surgical repair of a bilateral cleft lip and/or nasal deformity in one of two stages.
Modifiers such as 22 (increased procedural services), 51 (multiple procedures), 59 (distinct procedural service), 76 (repeat procedure by the same physician), 77 (repeat procedure by another physician), 78 (unplanned return to OR), and 79 (unrelated procedure) may be applicable depending on the circumstances of the case.
Medical necessity for 40702 is established by the presence of a bilateral cleft lip and/or nasal deformity affecting appearance, speech, and/or feeding. The procedure is intended to improve aesthetics, speech, and oral function.
The surgeon is responsible for all aspects of the procedure, including patient preparation, anesthesia management (in coordination with the anesthesiologist), surgical technique, and post-operative care. The surgeon's clinical responsibilities encompass precise incision and repair, ensuring proper tissue alignment and function, and achieving optimal cosmetic results.
In simple words: This code represents a surgical procedure to fix a split upper lip (cleft lip) and any associated nose problems on both sides of the face. It's one part of a two-part operation.
This CPT code describes the surgical repair of a bilateral cleft lip and/or nasal deformity performed as one stage of a two-stage procedure.The procedure involves precise incision and repair of the cleft margins, correction of the vermilion border (the red portion of the lip), meticulous re-alignment of muscle and skin layers to restore lip and nasal symmetry and function, and careful closure of all layers. The procedure is typically done after the patient reaches appropriate age and weight and is deemed healthy enough for surgery.
Example 1: A newborn infant is diagnosed with a bilateral complete cleft lip and palate.The surgeon performs 40702 as the first stage of a two-stage repair, focusing on the lip repair. The palate repair is completed later., A 6-month-old child presents with a bilateral incomplete cleft lip. The surgeon performs 40702 to correct the cleft lip and any associated nasal deformities in one surgical session. This is done as a single stage procedure., A child with a previously repaired bilateral cleft lip returns for a revision procedure to address residual asymmetry and scar revision. The surgeon uses code 40702 to document this secondary repair, which is performed as part of a two-stage procedure.
Complete patient history and physical examination, including details of the cleft lip and nasal deformity.Preoperative photographs. Intraoperative photographs and operative notes detailing surgical technique. Postoperative photographs and progress notes.Any complications encountered should be documented.
** Always ensure complete and accurate documentation to support medical necessity and code selection.Refer to the most recent CPT manual for comprehensive guidance.This information is current as of December 3, 2024.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- RVU: RVUs will vary depending on geographic location, facility type, and other factors. Consult your local Medicare Administrative Contractor (MAC) for specific payment rates and relative value units.
- Global Days : The global period for this procedure will vary depending on the complexity of the case and the surgeon's practice. It is recommended to check with the specific payer for details.
- Payment Status: Active
- Modifier TC rule: The technical component (TC) modifier is not applicable to this code.
- Fee Schedule : Fee schedules vary widely.Historical fee schedule information can be obtained from the AMA and payer-specific fee schedules.
- Specialties:Plastic Surgery, Craniofacial Surgery, Pediatric Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center