This page addresses follow-up questions and additional information pertinent to our webinar
Navigating Cleft Lip and Palate Repairs with Ease.

** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q:  For a second bilateral cleft lip repair surgery that is planned as a staged procedure, do I report code 40702 or 40720?
A:  Code 40720 describes a secondary repair of a cleft lip/nasal deformity. This is performed if a primary repair of a cleft lip/nasal deformity does not deliver favorable results. The defect is reopened and the surgical site is reclosed. Unfavorable results can include scar contracture, wound splitting or layers separating, and infection. Use modifier 50 if this is a bilateral procedure.
Code 40702 describes a primary bilateral procedure that is planned to be carried out in 2 stages. This code can be applied to both stage 1 and stage 2.

Q:  What the difference is between code 40840 (anterior vestibuloplasty) and code 40845 (complex vestibuloplasty).
A:  Vestibuloplasty codes from the range 40840-40844 are selected based on the anatomical area of the vestibule the surgeon is addressing. If this is done by performing incisions and repositioning the tissue with suturing, then use these codes. However, if the surgery involves changes to muscle attachments or uses soft tissue to enhance the ridge, then you should use code 40845 regardless of the location of the vestibuloplasty (for example anterior vs posterior).

Q:  Can code 42225 for a palatoplasty with pharyngeal flap creation can be billed a second time if a revision to the flap is required a year after the initial surgery.
A:  CPT Assistant (October 2019 page 10) explains that because the pharyngeal flap was created in a previous surgery, a revision procedure such as a partial pharyngeal flap take-down, should be reported with code 42950 Pharyngoplasty (plastic or reconstructive operation on pharynx) and not code 42225.