by Raquel Shumway
December 28th, 2017
Cleft palate and cleft lip diagnoses medical in nature and as such should be reported using the Current Procedural Terminology (CPT) codes instead of the Current Dental Terminology (CDT) codes. As such, Evaluation and Management (EM) services should be reported for the initial encounter with the patient and follow-up care until the surgery, 99024 for postoperative services during the 90-day global period, and then EM services for any remaining evaluations of the cleft repairs after the global period has ended.
|Common Codes for Cleft Surgery Services|
|40650-40799||Repairs to Lips and Nasal Deformity|
|42200-42299||Cleft Palate Surgery (Palatoplasty)|
|20902||Bone graft, any donor area; major or large|
|30400-30630||Repair Procedures on the Nose (ie, rhinoplasty, fistula repair, septoplasty, etc.)|
|14040-14041, 14060-14061||Adjacent tissue transfer or rearrangement|
|15120-15261, 15576||Skin reconstruction and repairs|
TIP: When reporting an unlisted procedure, always put the procedure name in box 19 (or on UB04 FL80 Remarks box), and attach supporting documentation (i.g., operative report, claim, preauthorization if available) for manual review.
|Modifiers Commonly Reported with Cleft Surgical Services|
|Modifier with Description||Tips|
|50||Bilateral procedure||Check payer-specific preferences for modifier usage (Medicare requires a single claim line with modifier 50, while others may require individual claim lines with RT and LT)|
|51||Multiple procedures||Medicare does not require modifier 51 as those edits have been hard coded into their systems. Other payers may require them so always verify payer-specific policies.|
|52||Reduced services||Identify any portion of the procedure not performed in the operative report, and why.|
|58||Planned, staged, or related procedure or service by the same physician during the 90-day global surgical period.||Documentation should clearly identify the services performed at intervals, or stages that require a purposeful return to the operating room.|
|59||Distinctly separate services||Medicare accepts modifier 59 or one of the X-[EPSU] modifiers. Modifier 59 (or an appropriate X-[EPSU] modifier) should be reported only when an NCCI edit exists and the documentation supports the approved reasons for overriding the edit. If appended when no NCCI edit exists, the claim may be denied. The X-[EPSU] modifiers include: XE: Separate encounter XP: Separate provider XS: Separate structure and XU: Unusual non-overlapping service|
|66||Surgical team||Difficult cases or crossover cases often require a surgical team.|
It is important that the assistant surgeon append this modifier and NOT the primary surgeon. Coordinate with the coding department of the assistant surgeon so the claim is properly paid and the fee properly divided between the surgeons according to the modifier.
TIP: Report CPT codes for cleft evaluations and repairs instead of CDT codes.