How To Use CPT Code 40701

CPT 40701 describes the primary bilateral, one-stage procedure for the plastic repair of cleft lip/nasal deformity. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 40701?

CPT 40701 is used to describe the surgical repair of a cleft lip defect or nasal deformity in one operation. This code specifically applies to a bilateral procedure, meaning it addresses both sides of the lip or nose.

2. Official Description

The official description of CPT code 40701 is: ‘Plastic repair of cleft lip/nasal deformity; primary bilateral, 1-stage procedure.’

3. Procedure

1. The provider begins by making incisions along the margins of the cleft surface, extending from the mouth to the nostril on both sides.
2. These incisions are carried through the full thickness of the mucosa, muscle, and skin.
3. The provider then corrects the vermilion border, which is the external red area of the upper and lower lips.
4. During the procedure, the provider aims to achieve symmetry in the correction of the cleft lip or nasal deformity.

4. Qualifying circumstances

CPT 40701 is applicable when a patient presents with a cleft lip or nasal deformity that requires surgical repair. The procedure is performed in one operation and addresses both sides of the lip or nose. It is important to note that this code is specific to bilateral repairs.

5. When to use CPT code 40701

CPT code 40701 should be used when a plastic surgeon performs a primary, one-stage procedure to repair a bilateral cleft lip or nasal deformity. It is important to ensure that the patient meets the necessary criteria for surgery, such as age, weight, and overall health.

6. Documentation requirements

To support a claim for CPT 40701, the provider must document the following information:

• Patient’s diagnosis of cleft lip or nasal deformity
• Details of the surgical procedure performed, including the specific techniques used
• Date of the surgery
• Any complications or additional procedures performed during the same operation
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 40701, ensure that the procedure meets the criteria for a primary bilateral, one-stage repair of cleft lip/nasal deformity. It is important to accurately document the procedure and any additional services provided during the same operation. Report other related codes, such as 40700 or 40702, depending on the specific circumstances of the surgery.

8. Historical information

CPT 40701 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A plastic surgeon performs a primary bilateral, one-stage repair of a cleft lip in a ten-week-old baby.
2. A patient with a bilateral cleft lip undergoes a surgical procedure to correct the deformity in one operation.
3. A plastic surgeon corrects a cleft lip and nasal deformity in a single procedure, addressing both sides of the lip and nose.
4. A ten-pound infant with good overall health receives a primary bilateral repair of a cleft lip.
5. A plastic surgeon performs a one-stage procedure to repair a bilateral cleft lip and nasal deformity in a patient.
6. A patient with a complete bilateral cleft lip undergoes a surgical repair in one operation.
7. A plastic surgeon corrects a cleft lip and nasal deformity on both sides of the lip and nose during a single procedure.
8. A primary bilateral repair of a cleft lip is performed by a plastic surgeon in a patient with good health.
9. A plastic surgeon addresses both sides of a cleft lip and nasal deformity in one operation.
10. A patient with a bilateral cleft lip receives a surgical repair in a single procedure.