CPT code 42215 is used to describe the surgical procedure for reconstructing a cleft palate in patients.
CPT code 42215 is used to describe a surgical procedure for reconstructing a cleft palate. This code specifically refers to the repair of the soft and hard palate in patients who have a cleft palate, which is a congenital condition where there is an opening or gap in the roof of the mouth. The procedure aims to restore normal function and appearance, improving the patient's ability to eat, speak, and breathe effectively.
For CPT code 42215 (Reconstruct cleft palate), the following modifiers may be applicable:
1. Modifier 22 - Increased Procedural Services: Used when the work required to provide a service is substantially greater than typically required.
2. Modifier 51 - Multiple Procedures: Used when multiple procedures are performed during the same surgical session.
3. Modifier 52 - Reduced Services: Used when a service or procedure is partially reduced or eliminated at the physician's discretion.
4. Modifier 53 - Discontinued Procedure: Used when a procedure is discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
5. Modifier 59 - Distinct Procedural Service: Used to indicate that a procedure or service was distinct or independent from other services performed on the same day.
6. Modifier 62 - Two Surgeons: Used when two surgeons work together as primary surgeons performing distinct parts of a procedure.
7. Modifier 66 - Surgical Team: Used when a team of surgeons is required to perform a complex procedure.
8. Modifier 76 - Repeat Procedure or Service by Same Physician: Used when a procedure or service is repeated by the same physician subsequent to the original procedure or service.
9. Modifier 77 - Repeat Procedure by Another Physician: Used when a procedure or service is repeated by another physician subsequent to the original procedure or service.
10. Modifier 78 - Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: Used when a related procedure is performed during the postoperative period of the initial procedure.
11. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: Used when an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure.
12. Modifier 80 - Assistant Surgeon: Used when an assistant surgeon is required during the procedure.
13. Modifier 81 - Minimum Assistant Surgeon: Used when a minimum assistant surgeon is required during the procedure.
14. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): Used when an assistant surgeon is required and a qualified resident surgeon is not available.
15. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant at surgery: Used when these non-physician practitioners assist in surgery.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.
CPT code 42215 is reimbursed by Medicare. This code is listed on the Medicare Physician Fee Schedule (MPFS), indicating that it is a covered service. However, reimbursement may vary depending on factors such as geographic location and specific Medicare Administrative Contractor (MAC) policies. Providers should consult their local MAC for specific coverage and payment guidelines related to this procedure.
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