tci Outpatient Facility Coding Alert - 2020 Issue Q1

Reader Question: Consider Patient History Before Reporting 42225

Question: How should I code an operative note note that involves the surgeon performing a partial flap takedown as part of a revision of a pharyngeal flap procedure performed two years prior? Montana Subscriber Answer: The physician may only perform a palatoplasty with attachment of a pharyngeal flap once; therefore, code 42225 (Palatoplasty for cleft palate; attachment pharyngeal flap) is out of the question. Furthermore, the October 2019 issue of CPT® Assistant covers this topic, in which it recommends that you should instead report 42950 (Pharyngoplasty (plastic or reconstructive operation on pharynx)) for the revision “because the flap...

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