How To Use CPT Code 40700

CPT 40700 describes the surgical repair of a partial or complete cleft lip defect or nasal deformity. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 40700?

CPT 40700 is used to describe the surgical repair of a partial or complete cleft lip defect or nasal deformity. This code specifically applies to a unilateral procedure, meaning it is used when the repair is performed on one side only.

2. Official Description

The official description of CPT code 40700 is: ‘Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral.’

3. Procedure

1. The provider begins by making incisions on either side of the cleft surface, extending from the mouth to the nostril.
2. The incisions are carried through the full thickness of the mucosa, muscle, and skin.
3. The provider corrects the vermilion border, which is the external red area of the upper and lower lips.
4. The procedure aims to surgically correct the cleft lip or nasal deformity.

4. Qualifying circumstances

CPT 40700 is applicable when a patient presents with a partial or complete cleft lip defect or nasal deformity that requires surgical repair. The procedure is performed unilaterally, meaning it is done on one side only. It is important to note that this code is not used for bilateral repairs.

5. When to use CPT code 40700

CPT code 40700 should be used when a provider performs a primary, partial or complete, unilateral repair of a cleft lip or nasal deformity. It is important to ensure that the procedure is performed on one side only and not bilaterally.

6. Documentation requirements

To support a claim for CPT 40700, the provider must document the following information:

• Patient’s diagnosis of a cleft lip defect or nasal deformity
• Details of the surgical repair performed, including the specific techniques used
• Date of the procedure
• Any additional relevant information, such as preoperative evaluation or postoperative care
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 40700, ensure that the procedure meets the criteria for a unilateral repair of a cleft lip or nasal deformity. It is important to accurately document the procedure and any additional services provided. Report additional codes, such as 40701 or 40702, depending on whether the surgery is bilateral or requires multiple stages.

8. Historical information

CPT 40700 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A surgeon performs a primary, unilateral repair of a complete cleft lip in a newborn baby.
2. A plastic surgeon corrects a partial cleft lip deformity unilaterally in a 6-month-old infant.
3. A maxillofacial surgeon performs a primary, unilateral repair of a complete cleft lip in a 10-year-old child.
4. A plastic surgeon surgically corrects a partial cleft lip defect unilaterally in a 16-year-old teenager.
5. A reconstructive surgeon performs a primary, unilateral repair of a complete cleft lip in an adult patient.
6. A pediatric plastic surgeon corrects a partial cleft lip deformity unilaterally in a 2-year-old toddler.
7. A maxillofacial surgeon performs a primary, unilateral repair of a complete cleft lip in a 4-year-old child.
8. A plastic surgeon surgically corrects a partial cleft lip defect unilaterally in a 20-year-old adult.
9. A reconstructive surgeon performs a primary, unilateral repair of a complete cleft lip in a 30-year-old patient.
10. A pediatric plastic surgeon corrects a partial cleft lip deformity unilaterally in a 12-year-old adolescent.