2025 CPT code 42210

Palatoplasty for cleft palate, with closure of alveolar ridge; with bone graft to alveolar ridge (includes obtaining graft).

Yes, applicable modifiers are:22: Increased Procedural Services51: Multiple Procedures52: Reduced Services53: Discontinued Procedure54: Surgical Care Only55: Postoperative Management Only56: Preoperative Management Only58: Staged or Related Procedure or Service by the Same Physician during the Postoperative Period59: Distinct Procedural Service73: Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia74: Discontinued Outpatient Hospital/ASC Procedure After Administration of Anesthesia76: Repeat Procedure by Same Physician77: Repeat Procedure by Another Physician78: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure during the Postoperative Period79: Unrelated Procedure by the Same Physician during the Postoperative Period80: Assistant Surgeon81: Minimum Assistant Surgeon82: Assistant Surgeon (when qualified resident surgeon not available)99: Multiple ModifiersAnd other less common modifiers.

Medical necessity for this procedure is established by the presence of a cleft palate and alveolar ridge defect, which can cause difficulties with feeding, speech, and facial development. The bone graft is necessary to provide structural support and facilitate normal growth.

IMPORTANT For other palatoplasty procedures, see 42205 through 42225. For other repair procedures of the palate, see 42226 through 42235.

In simple words: This surgery fixes a birth defect called a cleft palate, which is a gap in the roof of the mouth. The surgeon closes this gap and also fixes any gaps in the gums where teeth come from, using a bone graft from another part of the body.This helps the child eat, speak, and breathe better.

This procedure involves repairing a cleft palate (palatoplasty), closing the gap in the alveolar ridge, and performing a bone graft to the alveolar ridge. The bone graft material is typically obtained from the patient's hip or tibia. The procedure includes incising the mucosa, creating a pocket for the graft, packing the bone marrow into the pocket, closing the gum, and suturing the remaining defect(s).

Example 1: A 10-month-old infant with a cleft palate and alveolar ridge defect undergoes a palatoplasty with bone grafting to close the gap., A teenager with a history of cleft palate repair requires a revision palatoplasty with bone grafting to address residual alveolar ridge defects and improve speech., A child with a cleft palate undergoes a staged repair, with the initial surgery addressing the soft palate and the subsequent procedure including closure of the alveolar ridge with bone grafting.

Documentation should include details of the cleft palate, size and location of the alveolar ridge defect, type of bone graft used, operative technique, and any complications encountered. Pre- and postoperative photographs are also helpful.

  • Revenue Code: P1G - MAJOR PROCEDURE - OTHER
  • Specialties:Plastic Surgery, Oral and Maxillofacial Surgery, Otolaryngology (ENT)
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