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The procedure described by CPT® Code 42182 pertains to the repair of a laceration of the palate that exceeds 2 cm in length or is classified as complex. A laceration refers to a tear or cut in the tissue, and in this case, it specifically involves the palate, which is the roof of the mouth. The repair process begins with the irrigation of the laceration to cleanse the wound, followed by debridement, which is the removal of any non-viable or contaminated tissue to promote healing. A layered closure technique is employed, utilizing sutures to meticulously close the wound in multiple layers. This method is essential to ensure that the underlying tissues are properly aligned and secured, which aids in optimal healing and minimizes the risk of complications. During the procedure, the surgeon may undermine the tissues using scissors or a scalpel. This technique is crucial as it helps to reduce tension on the wound edges, thereby facilitating a more effective closure and reducing the likelihood of scarring. Control of bleeding is an important aspect of the procedure, which may be achieved through chemical means or electrocautery. The deepest layers of the tissue are closed with absorbable sutures, ensuring that the knots are buried to prevent irritation or discomfort. The superficial layer is then closed with careful attention to the alignment and eversion of the wound edges, which is vital to prevent the formation of a depressed scar. It is important to note that this code is specifically designated for lacerations that are over 2 cm or those that require a complex repair, which may involve extensive debridement and/or undermining of tissue. In cases where additional support is necessary to secure the closure, stents or retention sutures may be utilized. For lacerations measuring 2 cm or less, CPT® Code 42180 should be used instead.
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The procedure associated with CPT® Code 42182 is indicated for the repair of lacerations of the palate that are greater than 2 cm in length or those that are deemed complex. The following conditions may warrant this procedure:
The procedure for repairing a laceration of the palate over 2 cm or complex in nature involves several critical steps, each designed to ensure optimal healing and minimize complications:
After the completion of the procedure, post-operative care is essential to ensure proper healing and to monitor for any complications. Patients may be advised to follow specific care instructions, which could include keeping the area clean and dry, avoiding certain activities that may stress the repair, and attending follow-up appointments for suture removal or assessment of healing. It is also important to monitor for signs of infection, such as increased redness, swelling, or discharge from the wound site. The expected recovery time may vary depending on the extent of the laceration and the complexity of the repair, but patients should be informed about what to expect during their healing process.
| Short Descr | REPAIR PALATE | Medium Descr | REPAIR LACERATION PALATE >2 CM/COMPLEX | Long Descr | Repair, laceration of palate; over 2 cm or complex | 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 | Hospital Part B services paid through a comprehensive APC | 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) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 33 - Other OR therapeutic procedures on nose, mouth and pharynx |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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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| Pre-1990 | Added | Code added. |
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