2025 CPT code 42215
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Surgery - Repair Procedures on the Palate and Uvula Surgery Feed
Major revision of a previous cleft palate repair (palatoplasty).
Modifiers may be applicable depending on the circumstances of the procedure.For instance, modifier 51 (multiple procedures) might apply if other procedures are performed during the same session.Modifier 22 (increased procedural services) may be used if the procedure is significantly more complex than usual. Consult current coding guidelines for the most up-to-date information on appropriate modifiers.
Medical necessity for a major revision of a cleft palate repair is established when the initial repair has resulted in significant functional impairment (e.g., impaired speech, swallowing difficulties, velopharyngeal incompetence), or when there is evidence of a fistula, recurrent infection, or severe scarring that compromises palatal integrity.
The clinical responsibility rests with the surgeon who performs the major revision of the cleft palate. This includes pre-operative assessment, surgical planning, execution of the palatoplasty revision, post-operative care, and management of any complications.
In simple words: This surgery fixes problems from a previous cleft palate operation.The doctor repairs any holes, infections, or scars in the roof of the mouth. The specific technique depends on the problem and patient's age.The goal is to close the opening and make the palate work normally for eating, speaking, and breathing.
This CPT code encompasses the surgical revision of a prior cleft palate repair.The procedure addresses complications such as wound splitting, infection, or scarring from the initial palatoplasty. The specific surgical technique employed will depend on the nature and extent of the defect, the patient's age, and whether the repair is performed in a single session or multiple stages.The surgeon may utilize various methods to correct the abnormal position of soft palate muscles, reconstruct tissue defects using flaps, excise scar tissue or infected tissue, and meticulously close the resulting defect with tension-free sutures. Uvula repair may also be included to restore its normal contour and position. The procedure is performed under general anesthesia, typically with an endotracheal tube and mouth gag in place.
Example 1: A 5-year-old child presents with a fistula (hole) in the palate following a previous cleft palate repair at age 1. The surgeon performs a major revision using a flap technique to close the fistula., A 10-year-old patient has significant scarring and restriction of soft palate movement from a previous cleft palate repair.The surgeon performs a major revision to release the scar tissue and reposition the muscles for improved speech and swallowing., An adult patient experiences recurrent infection and breakdown of the palate following prior cleft palate repair. The surgeon performs a major revision with extensive debridement of infected tissue, tissue reconstruction with flaps, and closure with sutures.
* Detailed preoperative assessment including history of previous cleft palate repair and any complications.* Operative report describing the specific surgical technique used, the extent of tissue repair or reconstruction, and any complications encountered.* Postoperative progress notes detailing recovery, management of complications, and follow-up care.* Relevant imaging studies (if obtained) to show the extent of the defect.
** Thorough documentation is essential for accurate coding and reimbursement. This includes detailed descriptions of the pre-operative condition, the surgical technique employed, and the post-operative course.Variations in surgical approaches exist, and the documentation must accurately reflect the specific procedures performed.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- RVU: This information requires access to a current fee schedule and may vary based on location and payer. Consult a relevant fee schedule for the most accurate RVU data.
- Global Days : The global period for this procedure is not specified in the provided data.The global period (if any) would be determined by the specific payer's guidelines and may vary based on the extent of the procedure.
- Payment Status: Active
- Modifier TC rule: The applicability of a Technical Component (TC) modifier depends on the specific circumstances and payer guidelines. Refer to the payer's specific guidelines and coding conventions.
- Fee Schedule : Historical fee schedule data is not available in the provided sources. Consult a reliable fee schedule database for historical reimbursement information.
- Specialties:Plastic Surgery, Craniofacial Surgery, Otolaryngology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center