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A palatoplasty for cleft palate is a surgical procedure aimed at correcting a congenital deformity known as cleft palate, which occurs when the roof of the mouth does not develop properly during fetal development, resulting in an opening that connects the oral cavity to the nasal cavity. This condition can manifest in various forms, affecting either the hard palate at the front of the mouth, the soft palate at the back, or both. Cleft palate may occur in isolation or in conjunction with other congenital anomalies, with cleft lip being the most frequently associated defect. The procedure described by CPT® Code 42210 involves not only the closure of the cleft but also the repair of the alveolar ridge, which is the bony ridge containing the sockets of the teeth. This specific procedure includes the use of a bone graft to fill the defect in the alveolar ridge, which is essential for proper dental arch formation and function. The process involves meticulous surgical techniques to ensure that the oral and nasal cavities are properly separated and that the structural integrity of the palate is restored, facilitating normal speech and feeding functions post-surgery.
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The procedure described by CPT® Code 42210 is indicated for patients with a cleft palate, particularly when there is a need for closure of the alveolar ridge and the use of a bone graft. The following conditions may warrant this surgical intervention:
The procedure for CPT® Code 42210 involves several critical steps to ensure effective repair of the cleft palate and alveolar ridge. The following outlines the procedural steps:
Post-procedure care following a palatoplasty with bone grafting is essential for optimal recovery. Patients may experience swelling and discomfort in the surgical area, which can be managed with prescribed pain relief medications. It is important to monitor for any signs of infection at the surgical site. Follow-up appointments will be necessary to assess the healing process and the integration of the bone graft. Patients are typically advised on dietary modifications to avoid irritation to the surgical site and to promote healing. Speech therapy may also be recommended to assist with any speech difficulties that may arise following the procedure. Overall, the recovery process is closely monitored to ensure that the surgical goals are met and that the patient can achieve normal function in both speech and feeding.
| Short Descr | RECONSTRUCT CLEFT PALATE | Medium Descr | PALATOP CLSR ALVEOLAR RIDGE GRF ALVEOLAR RIDGE | Long Descr | Palatoplasty for cleft palate, with closure of alveolar ridge; with bone graft to alveolar ridge (includes obtaining graft) | Status Code | Active Code | Global Days | 090 - Major Surgery | 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) | 2 - Payment restriction for assistants at surgery does not apply 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) | P1G - Major procedure - Other | 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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. | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| Pre-1990 | Added | Code added. |
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