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Palatoplasty for cleft palate, specifically the attachment of a pharyngeal flap, is a surgical procedure aimed at correcting the anatomical and functional issues associated with a cleft palate. This procedure is typically considered a secondary intervention, which means it is performed after an initial palatoplasty has been conducted. The primary goal of this surgery is to achieve effective closure of the cleft defect while ensuring optimal velopharyngeal function. This function is crucial for normal activities such as eating, breathing, and producing intelligible speech. In some cases, patients may require additional surgical procedures to fully address the residual defects left after the initial repair. The attachment of a pharyngeal flap is one of the methods employed to enhance the closure of the cleft palate, thereby improving the patient's quality of life and functional outcomes. The procedure involves careful manipulation of the soft palate and surrounding tissues to create a flap that can be positioned to cover the defect, ultimately facilitating better communication and feeding capabilities for the patient.
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The procedure of palatoplasty for cleft palate with attachment of a pharyngeal flap is indicated for patients who have undergone an initial palatoplasty but continue to experience functional deficits. The following conditions may warrant this surgical intervention:
The procedure for attaching a pharyngeal flap during palatoplasty involves several critical steps to ensure successful outcomes. The following outlines the procedural steps:
Post-procedure care following the attachment of a pharyngeal flap is essential for ensuring proper healing and function. Patients may be monitored for any complications related to the surgical site, including infection or flap necrosis. Recovery typically involves a period of restricted activity to allow for healing, and patients may be advised on specific dietary modifications to accommodate the surgical changes. Follow-up appointments are crucial to assess the success of the procedure, monitor speech development, and address any ongoing functional issues. The healthcare team will provide guidance on rehabilitation strategies, including speech therapy, to support the patient's recovery and enhance communication abilities.
| Short Descr | RECONSTRUCT CLEFT PALATE | Medium Descr | PALATOP CL PALATE ATTACHMENT PHARYNGEAL FLAP | Long Descr | Palatoplasty for cleft palate; attachment pharyngeal flap | 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 | Non office-based surgical procedure added in CY 2008 or later; 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. | 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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