How To Use CPT Code 40702

CPT 40702 describes the surgical repair of a cleft lip defect or nasal deformity in one of a two-stage operation. 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 40702?

CPT 40702 can be used to describe the surgical repair of a cleft lip defect or nasal deformity in one of a two-stage operation. This code is applicable for a bilateral procedure.

2. Official Description

The official description of CPT code 40702 is: ‘Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 stages.’

3. Procedure

1. The provider performs an incision along the margins of the cleft surface from the mouth to the nostril on both sides.
2. The provider corrects the vermilion border, which is the external red area of the upper and lower lips.
3. The provider brings the muscle and skin together, closing the prepared margins on both sides in layers.
4. The provider closes the skin to complete the surgical repair.

4. Qualifying circumstances

Patients eligible for CPT 40702 are those with a cleft lip defect or nasal deformity that requires surgical repair. This code is specifically for a primary bilateral procedure performed in one of a two-stage operation.

5. When to use CPT code 40702

CPT code 40702 should be used when a provider performs a surgical repair of a cleft lip defect or nasal deformity in one of a two-stage operation. This code is applicable for a bilateral procedure.

6. Documentation requirements

To support a claim for CPT 40702, the provider must document the following information:

• Patient’s diagnosis and the need for surgical repair
• Details of the procedure performed, including the incision, correction of the vermilion border, and closure of the margins
• Date of the surgery
• Any additional relevant information, such as the patient’s response to the procedure
• Signature of the provider performing the surgery

7. Billing guidelines

When billing for CPT 40702, ensure that the surgery is a primary bilateral procedure performed in one of a two-stage operation. Follow the appropriate coding guidelines for reporting this procedure. Consider reporting other related codes if necessary, such as CPT 40700 or CPT 40701, depending on the specific circumstances of the surgery.

8. Historical information

CPT 40702 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 provider surgically repairs a cleft lip defect in one of a two-stage operation for a patient with a bilateral cleft lip.
2. A patient undergoes a surgical repair of a nasal deformity in one of a two-stage operation for a bilateral nasal deformity.
3. A provider performs a primary bilateral procedure to surgically correct a cleft lip and nasal deformity in one of a two-stage operation.
4. A patient with a bilateral cleft lip undergoes a surgical repair in one of a two-stage operation to improve their facial appearance and function.
5. A provider performs a surgical repair of a cleft lip defect and nasal deformity in one of a two-stage operation for a patient with a bilateral cleft lip and nasal deformity.
6. A patient undergoes a primary bilateral procedure to surgically correct a cleft lip and nasal deformity in one of a two-stage operation, improving their ability to eat, speak, and breathe.
7. A provider performs a surgical repair of a cleft lip defect in one of a two-stage operation, improving the patient’s facial symmetry and appearance.
8. A patient with a bilateral nasal deformity undergoes a surgical repair in one of a two-stage operation, improving their ability to breathe and reducing nasal congestion.
9. A provider performs a primary bilateral procedure to surgically correct a cleft lip and nasal deformity in one of a two-stage operation, improving the patient’s overall facial aesthetics.
10. A patient undergoes a surgical repair of a cleft lip defect and nasal deformity in one of a two-stage operation, enhancing their self-confidence and quality of life.