Coding for Cleft Lip and Palate Surgery - American Association of ...

15576 Formation of direct or tubed pedicle, with orwithout transfer; eyelids, nose, ears, lips, orintraoralCodes used to describe cleft palate surgery (Codes arelocated in the Digestive System heading under the Sectionof Palate and Uvula) to include the alveolus, anterior/posteriorhard palate and soft palate, are as follows:42200 Palatoplasy for cleft palate, soft and/or hardpalate only42205 Palatoplasty for cleft palate, with closure of alveolarridge; soft tissue only42210 Palatoplasty for cleft palate with bone graft toalveolar ridge (includes obtaining graft). Thisincludes grafting from the alveolar crest to thepiriform rim.• Note 1: To report a bone graft to an alveolarcleft as a secondary procedure forridge augmentation, without a palatoplasty,use code 21210. For example: a child hada successful alveolar graft at 9 years old,patient is now ready for a dental implant.Additional bone stock is needed to supportthe dental implant.• Note 2: When a separate surgeon harveststhe bone or other tissues through a separateskin incision use code 20902. See below• Note 3: regarding bilateral clefts. Themodifier -50 would logically apply, however,the Medicare, Medically Unlikely Edit(MUE) policy prohibits using the bilateralmodifier with the 42210. Therefore; there isno distinction between repair of a unilateraland bilateral alveolar cleft and there is nota separate bilateral cleft code. You mayconsider using the -22 (unusual difficulty)modifier for bilateral clefts.• Note 4: codes 42200, 42205, 42210, 30600and 42260 cannot be used together as aresult of the Correct Coding Initiative (CCIedits). However; it is appropriate to use themodifier -59, if the services are distinctlyseparate. For example, regarding a patientwith a naso-alveolar cleft and a oronasalfistula of the posterior hard palate (repairof the naso-alveolar fistula extending intothe anterior hard palate/premaxilla and thePAGE 2 Coding for Cleft Lip and Palate SurgeryCoding Papernaso-labial fistula is considered integral tothe alveolar cleft repair). If you choose torepair of a naso-alveolar cleft and oral–nasalfistula of the posterior hard palate at thesame time. Using 42210-59, 30600-59 (or42200-59 as appropriate) is acceptable, ifdenied an appeal is justified.41899 Extraction of teeth during cleft palate surgery.Specify difficulty with ICD-9/10 code. Forexample: removal of an impacted supernumerarytooth in the cleft (520.1) or removal of a decayederupted primary incisor in the cleft (521.0).42215 Palatoplasty for cleft palate; major revision42220 Palatoplasty for cleft palate, secondary lengtheningprocedure42225 Palatoplasty for cleft palate, attachment pharyngealflap42226 Lengthening of palate and pharyngeal flap42227 Lengthening of palate, with island flap42235 Repair of anterior palate, including vomer flap42260 Repair of nasolabial fistula20902 Bone harvest any area, major or large. Codeused for obtaining autogenous bone or othertissues through a separate skin incision by aseparate surgeon than performing the primaryprocedure. If the primary procedure “includesobtaining the graft” use the -52 modifier on theprimary procedure for reduced services or bothsurgeons may report the primary procedure codeappended by the -62 modifier. For example: surgeon#1 repairs a unilateral cleft: use 42210-52.Surgeon #2 harvest bone from the iliac crest anddoes not assist in the surgery: use 20902-6230580 Repair fistula; oromaxillary (combine with31030 if antrotomy is included)30600 Repair oral-nasal fistulaAdditional procedure codes include:30400-30630 Rhinoplasty, septoplasty, nasal regionrepair codes

Recommendations by the AAOMS Committee on HealthCare and Advocacy (CHCA) for procedures used fortreating patients with cleft lip and palate deformities forwhich there are no specific CPT codes:Prosthethetic devices used as adjuncts for cleft lip andpalate treatment:42280 Maxillary impression for palatal prosthesis: Use42280 for taking an impression in the office, youmay choose to use the -22 modifier if the impressionis made under anesthesia.42281 Insertion palatal prosthesis: use 42281 if theprosthesis is fabricated by a laboratory (NOTby the provider) and delivered/inserted by theprovider where limited adjustments are required.21085 Impression and custom preparation of oral surgicalsplint:The AAOMS CHCA does NOT recommend theuse of this code for cleft palate prosthesis. Thiscode should be used for provider fabricatedsplints in conjunction with orthognathic surgery.21084 Speech aid prosthesis21076 Prepare facial/oral prosthesis: includes takingimpression(s), custom preparation and delivery/insertion for the prosthesis. It is assigned a 10day global surgical package, therefore, Subsequentadjustments beyond 10 days may be billedwith and E&M code. Pre-surgical Nasoalveolarmoulding (NAM) best fits within this codeTongue Flap for closure of a large palatal fistula:15576 Tongue flap: anterior of posterior based pedicledflap.21110 Application of intermaxillary fixation: MMF notin conjunction with facial fracture.15600 Sectioning (division and inset) of the flap at thetrunk: use this code when the tongue flap is “takendown” post-op. Includes plasty of the dorsaltongue and pedicle attached to the palate.The AAOMS Committee on Health Care and Advocacyrecommends that the oral and maxillofacial surgeon usethe CPT codes described for cleft lip and palate surgeryrather than the American Dental Association’s CurrentDental Terminology (CDT) codes.Coding PaperIII. MODIFIERS FOR CLEFT LIP AND PALATESURGERYThe following code modifiers may have some applicationin the reporting of services for cleft lip and palate surgery.-50 Bilateral procedure-51 Multiple procedures-52 Reduced services-58 A planned, staged or related procedure/serviceby the same physician during the 90 day GSPpostoperative period.-59 distinctly separate services-62 Two surgeons-66 Surgical team-80 Assistant surgeonIV. DIAGNOSIS CODING FOR CLEFT LIP ANDPALATE SURGERYCorrect usage of the CPT (procedural) and the ICD-9-CM(diagnosis) Coding Systems require that the appropriateICD-9-CM codes be linked to the surgical procedureslisted in the CPT universe. There is a great degree ofspecificity that has been built into the ICD-9-CM sectionunder congenital anomalies to cover the spectrum ofdisorders associated with the cleft lip and palate deformity.The following fifth-digit of the ICD-9-CM codes are usedto describe the different congenital anomalies:749.0 Cleft Palate749.00 Cleft palate, unspecified749.01 Unilateral, complete749.02 Unilateral, Incomplete749.03 Bilateral, complete749.04 Bilateral, incomplete749.1 Cleft Lip (Cheiloschisis, harelip, congenitalfisure of lip, and Labium leporinum)749.10 Cleft lip, unspecified749.11 Unilateral, completePAGE 3 Coding for Cleft Lip and Palate Surgery

749.12 Unilateral, incomplete749.13 Bilateral, complete749.14 Bilateral, incomplete749.2 Cleft Palate with Cleft Lip (Cheilopalatoschisis)749.20 Cleft palate with cleft lip, unspecified749.21 Unilateral, complete749.22 Unilateral, incomplete749.23 Bilateral, complete749.24 Bilateral, incomplete749.25 Other combinations750.2 Other Specified Anomalies of Mouth andPharynx750.25 Congenital fistula of lipCongenital (mucous) lip pits520.1 Tooth codes pertinent to cleft palate codes520.0 Congenital missing teeth520.6 Impacted teeth, eruption disturbance520.1 Supernumerary toot520.3 Mottled teeth520.1 Decayed teeth521.6 Ankylosed tooth“V51 Aftercare involving the use of plastic surgery”should be used when applicable for reportingplastic surgery following healed injury oroperationCoding PaperV. Global Surgical Package (GSP)The global surgical package concept is in effect for theCPT codes used to describe cleft lip and palate surgery.It is defined by CPT that use of the procedure code on aclaim form will cover one related E/M encounter on thedate immediately prior to or on the date of the procedure(subsequent to the decision for surgery), the surgical care(the operation), and both post-operative care in the hospitaland in the office. The global period of follow-up for cleftsurgical services is generally 90 days.Note: This paper should not be used as the sole reference in coding.Both diagnosis and treatment codes change frequently, and insurancecarriers may differ in their interpretations of the codes.Coding and billing decisions are personal choices to be made byindividual oral and maxillofacial surgeons exercising their own professionaljudgment in each situation. The information provided to you inthis paper is intended for educational purposes only. In no event shallAAOMS be liable for any decision made or action taken or not takenby you or anyone else in reliance on the information contained in thisarticle. For practice, financial, accounting, legal or other professionaladvice, you need to consult your own professional advisers.This is one in a series of AAOMS papers designed to provideinformation on coding claims for oral and maxillofacial surgery(OMS). This paper discusses coding for Cleft Lip and PalateSurgery. This paper is to aid the oral and maxillofacial surgeonwith proper diagnosis (ICD-9-CM) and treatment (CPT/CDT)coding for Cleft Lip and Palate Surgery. When indicated, you willbe referred to the appropriate area of the coding books where theprinciples of coding illustrated in this paper may be applied.Proper coding provides a uniform language to describe medical,surgical, and dental services. Diagnostic and procedure codesare continually updated or revised. The AAOMS Committee onHealth Care and Advocacy has developed these coding guidelinesin order to assist the membership to use the coding systemseffectively and efficiently.© 2013 American Association of Oral and Maxillofacial Surgeons.No portion of this publication may be used or reproduced withoutthe express written consent of the American Association of Oraland Maxillofacial Surgeons.Revised March 2013PAGE 4 Coding for Cleft Lip and Palate Surgery