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The procedure described by CPT® Code 42180 involves the surgical repair of a laceration of the palate that measures up to 2 centimeters in length. This procedure is essential for restoring the integrity of the oral cavity following an injury. Initially, the laceration is thoroughly irrigated to cleanse the wound and remove any debris, which is a critical step in preventing infection. Following irrigation, debridement may be performed as necessary to excise any non-viable tissue that could impede healing. A layered closure technique is then employed, which involves suturing the wound in multiple layers to ensure a secure and effective repair. To minimize tension on the wound, the surrounding tissues are undermined using surgical instruments such as scissors or a scalpel. This technique helps to facilitate a more comfortable healing process and reduces the risk of complications. Control of any bleeding during the procedure is achieved through the use of chemical agents or electrocautery, which cauterizes the tissue and prevents excessive blood loss. The deepest layers of the tissue are closed with absorbable sutures, and the knots are buried to avoid irritation to the surrounding mucosa. The superficial layer is then meticulously closed, ensuring that the edges of the wound are aligned and everted. This careful alignment is crucial to prevent the formation of a depressed scar, which can occur if the edges are not properly positioned. For lacerations measuring 2 cm or less, the appropriate code to use is 42180. In contrast, for lacerations exceeding 2 cm or those requiring a more complex repair, such as extensive debridement or undermining, the code 42182 should be utilized.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 42180 is indicated for the repair of lacerations of the palate that are up to 2 centimeters in length. This procedure is typically performed in cases where the laceration may compromise the function or aesthetics of the oral cavity, and timely intervention is necessary to promote healing and prevent complications such as infection or scarring.
The procedure begins with the thorough irrigation of the laceration to cleanse the wound and remove any foreign material or debris. This step is crucial for reducing the risk of infection and ensuring a clean surgical field. Following irrigation, the surgeon may perform debridement, which involves the removal of any non-viable or damaged tissue that could hinder the healing process. Next, a layered closure technique is employed. This involves suturing the wound in multiple layers, starting with the deepest layers of tissue. The surgeon undermines the surrounding tissues using surgical scissors or a scalpel, which helps to relieve tension on the wound edges and facilitates a more effective closure. Bleeding control is an essential aspect of the procedure, and it is achieved through the use of chemical agents or electrocautery, which cauterizes the tissue to prevent excessive blood loss. Once hemostasis is achieved, the deepest layers of the wound are closed using absorbable sutures, with the knots buried to minimize irritation to the surrounding tissues. The final step involves closing the superficial layer of the wound. The surgeon carefully aligns the edges of the laceration, ensuring that they are everted to prevent the formation of a depressed scar. This meticulous attention to detail during the closure process is vital for achieving optimal cosmetic and functional outcomes.
After the procedure, the patient may be monitored for any signs of complications, such as infection or excessive bleeding. Instructions for post-operative care will typically include guidelines on oral hygiene, dietary modifications, and activity restrictions to promote healing. Follow-up appointments may be scheduled to assess the healing process and to remove any non-absorbable sutures if used. Patients should be advised to report any unusual symptoms, such as increased pain, swelling, or discharge from the surgical site, to their healthcare provider promptly.
| Short Descr | REPAIR LAC PALATE<2 CM | Medium Descr | REPAIR LACERATION PALATE <2 CM | Long Descr | Repair, laceration of palate; up to 2 cm | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 33 - Other OR therapeutic procedures on nose, mouth and pharynx |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2024-01-01 | Changed | Short and Medium Descriptions changed. |
| Pre-1990 | Added | Code added. |
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