Construct Better Billing of Cleft Lip and Palate Repairs
Let realistic cases of congenital facial disorders help you report these services correctly.
by Victoria M. Moll, CPC, CPMA, CPRC
Cleft lip and palate are the most common congenital facial disorders, presenting challenges for reconstruction. Coordinated care with multispecialty teams, staged procedures, and complex revisions are often necessary for optimal outcomes. Most modern countries can easily detect a cleft through ultrasound. In the United States, approximately 2,650 babies are born with a cleft palate each year, and 4,440 babies are born with a cleft lip (and perhaps a cleft palate, as well).
Differences in ICD-9-CM and ICD-10-CM Coding
Knowing whether the cleft is complete or incomplete, and whether it’s unilateral or bilateral, is necessary to assign the correct diagnosis code from ICD-9-CM category 749 – Cleft palate and cleft lip. ICD-10-CM code selection Q35-Q37 does not differentiate between incomplete or complete clefts, but does include codes distinguishing between hard and soft palate clefts, as shown in Table A.
Cleft Lip Repairs
Cleft lip develops when the tissues forming the upper lip do not fuse. This can happen in an incomplete fashion, where the lip is separated but the nasal sill remains intact; or a complete fashion, where the cleft extends through the nasal sill.
Cleft lip repair is typically performed by the time the child is three months old. The initial reconstructive surgery is assigned one of the following codes:
40700 Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral
40701 Plastic repair of cleft lip/nasal deformity; primary, bilateral 1-stage procedure
40702 Plastic repair of cleft lip/nasal deformity; primary, bilateral, 1 of 2 stages
40761 Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle.
When a bilateral cleft lip is repaired with a two-stage procedure, report 40702 for each of the two stages. The code descriptor indicates “1 of 2 stages,” but does not differentiate between the first and second stages.
If the patient develops a deformity requiring a revision of the previous repair, report 40720 Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure. Revisions typically are necessary due to poor healing, dehiscence, or scar contracture from the initial surgery.
|Table A: Diagnosis coding differences|
|Cleft lip, bilateral, complete||749.13
Cleft lip, bilateral, complete
|Q36.0 Cleft lip, bilateral|
|Cleft palate, unilateral, incomplete||749.02
Cleft palate, unilateral, incomplete
Cleft palate, unspecified
|Cleft lip with cleft palate unilateral, incomplete||749.22
Cleft palate with cleft lip, unilateral, incomplete
Unspecified cleft palate with unilateral cleft lip
Diagnosis: Unilateral left cleft lip
Procedure: The patient was prepped, anesthetized, and marked, including the Cupid’s bow and the cut for the rotation flap. The lateral element was marked, incisions were made, and the skin and muscle was freed up, including freeing the muscle from the ala as well as the skin mucosa. Flaps were designed, elevated, and rotated without tension to fill the defects. The flaps were sutured without undue tension. Dermabond® and Steri-Strips™ were placed. The patient tolerated the procedure well and was discharged to recovery in stable condition.
Procedure coding: 40700
Diagnosis: Secondary cleft lip deformity
Procedure: Attention was turned to the excess membrane of the upper right area of the lip, and the area was marked for excision and clamped. This portion was shaved, trimmed, and sutured. The vermillion border of the lower lip was noted to have some unsuitable residual scar and resection was performed. Sutures were placed, as well as antibiotic ointment and a dressing.
Procedure coding: 40720
Cleft Palate Repair
Cleft palates often are repaired when a patient is approximately one year old. In a complete cleft palate, the defect extends through the soft and hard palate. An incomplete cleft palate has a separation that partially spreads through the roof of the mouth.
A simple repair of a cleft palate with elevation of the adjacent mucosa to close the defect is coded 42200 Palatoplasty for cleft palate, soft and/or hard palate only. If the cleft extends through the aveolar ridge, report 42205 Palatoplasty for cleft palate, with closure of aveolar ridge; soft tissue only.
In some cases, a bone graft is harvested from the hip or the skull to complete closure, and is included in 42210 Palatoplasty for cleft palate, with bone graft to aveloar ridge (includes obtaining graft). Do not separately report harvesting of the bone unless performed by a surgeon other than the primary reconstructive surgeon. In such a case, report 20902 Bone harvest any area, major or large for the secondary surgeon and 42210-52 Reduced services for the primary surgeon. If two surgeons work as co-surgeons to complete the procedure, each should append modifier 62 Two surgeons to the procedure code, and each surgeon should dictate his or her own operative report.
If the initial repair of the cleft later results in wound splitting, scarring, infection, or developmental restrictions, a revisionary procedure may be necessary. Applicable CPT® codes are differentiated by the extent of the repair:
42215 Palatoplasty for cleft palate; major revision
42220 Palatoplasty for cleft palate; secondary lengthening procedure
42225 Palatoplasty for cleft palate; attachment pharyngeal flap
Although 42220 and 42225 include flap closures, the flap is an inherent part of the repair. Do not report an additional flap or adjacent tissue transfer code.
Diagnosis: Secondary cleft palate deformity
Procedure: Attention was turned to the wide cleft of the palate, which was exposed via a Dingman retractor. Lateral palatal flaps were separated between the nasal mucosa and the oral mucosa, and further dissection was carried out separating the muscle on both sides. The nasal mucosa was undermined laterally to the lateral palatal walls. Once this was done, the flaps were advanced and closed without tension. The patient tolerated the procedure well.
Procedure coding: 42215
Diagnosis: Unilateral cleft lip deformity of soft palate
Procedure: The patient was prepped and draped in a sterile fashion. The defect was identified and marked for revision. The adjacent mucosa was elevated and loosened from the bony palate. Pedicle flaps were developed, rotated, and utilized to increase the length of the soft palate. Multiple layers of sutures were placed for closure.
Procedure coding: 42220
Nasal deformities can arise during the teen years, when the face has become more developed. A revision can resolve potential breathing problems, as well as greatly improve the appearance of the nose. Codes 30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columella lengthening; tip only and 30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columella lengthening; tip, septum, osteotomies are most commonly used in these cases. Local grafts from adjacent structures are included in these codes.
With the myriad of reconstructive and revisionary procedures available in these cases, other codes may be applicable. As always, if the report is ambiguous about the services performed, query the provider and get an addendum to clarify any confusion.
Victoria M. Moll, CPC, CPMA, CPRC, is a coder for a large physician group. She has more than seven years of experience in billing and coding for hospitalists, obstetrics/gynecology, transplant services, general surgery, and plastic and reconstructive surgery. She previously worked as a coding instructor at a local technical school, and now serves as education officer in the Allentown, Pennsylvania, local chapter.