How To Use CPT Code 40761

CPT 40761 describes the plastic repair of cleft lip/nasal deformity using a cross lip pedicle flap, known as the Abbe-Estlander type. 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 40761?

CPT 40761 is used to describe the plastic repair of cleft lip/nasal deformity using a cross lip pedicle flap, specifically the Abbe-Estlander type. This procedure involves the sectioning and inserting of the pedicle flap to close the cleft lip and correct the nasal deformity. It is performed to improve both the functional and cosmetic appearance of the patient.

2. Official Description

The official description of CPT code 40761 is: ‘Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle.’

3. Procedure

1. The provider begins by making incisions on either side of the cleft surface, from the mouth to the nostril, ensuring the incision goes through the full thickness of the mucosa, muscle, and skin.
2. The vermilion border is corrected by turning the tissue downward to restore a normal shape.
3. A full thickness pedicle flap is created from the skin on the lower lip, ensuring it has a sufficient blood supply.
4. The flap is rotated on its pedicle to the desired location in the upper lip and sutured in place.
5. If a nasal deformity is present, the affected tissue is repaired.
6. The prepared margins are closed in layers, starting from the intraoral mucosa, through the muscle, and finally the skin.

4. Qualifying circumstances

CPT 40761 is performed on patients with cleft lip/nasal deformity who require plastic repair. This procedure is specifically used when a cross lip pedicle flap, known as the Abbe-Estlander type, is utilized. It is important to note that this code should not be used for cleft palate repair or other reconstructive procedures.

5. When to use CPT code 40761

CPT code 40761 should be used when performing a plastic repair of cleft lip/nasal deformity using a cross lip pedicle flap, specifically the Abbe-Estlander type. It is important to accurately document the procedure and ensure that it meets the criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 40761, the provider must document the following information:

• Patient’s diagnosis of cleft lip/nasal deformity
• Description of the procedure performed, including the use of a cross lip pedicle flap (Abbe-Estlander type)
• Date of the procedure
• Details of the incisions made and the closure of the cleft lip
• Documentation of any repairs made to nasal deformity
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 40761, ensure that the procedure meets the criteria outlined in the code description. It is important to accurately document the procedure and provide any necessary supporting documentation. Additionally, be aware of any specific guidelines or requirements from the payer regarding the use of this code.

8. Historical information

CPT 40761 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 performing a plastic repair of cleft lip/nasal deformity using a cross lip pedicle flap (Abbe-Estlander type) for a patient with a unilateral cleft lip.
2. A maxillofacial surgeon performing a plastic repair of cleft lip/nasal deformity using a cross lip pedicle flap (Abbe-Estlander type) for a patient with a bilateral cleft lip.
3. A reconstructive surgeon performing a plastic repair of cleft lip/nasal deformity using a cross lip pedicle flap (Abbe-Estlander type) for a patient with a unilateral cleft lip and nasal deformity.
4. A plastic surgeon performing a plastic repair of cleft lip/nasal deformity using a cross lip pedicle flap (Abbe-Estlander type) for a patient with a bilateral cleft lip and nasal deformity.
5. A craniofacial surgeon performing a plastic repair of cleft lip/nasal deformity using a cross lip pedicle flap (Abbe-Estlander type) for a patient with a unilateral cleft lip and severe nasal deformity.
6. A plastic surgeon performing a plastic repair of cleft lip/nasal deformity using a cross lip pedicle flap (Abbe-Estlander type) for a patient with a bilateral cleft lip and severe nasal deformity.
7. A maxillofacial surgeon performing a plastic repair of cleft lip/nasal deformity using a cross lip pedicle flap (Abbe-Estlander type) for a patient with a unilateral cleft lip and minor nasal deformity.
8. A reconstructive surgeon performing a plastic repair of cleft lip/nasal deformity using a cross lip pedicle flap (Abbe-Estlander type) for a patient with a bilateral cleft lip and minor nasal deformity.
9. A plastic surgeon performing a plastic repair of cleft lip/nasal deformity using a cross lip pedicle flap (Abbe-Estlander type) for a patient with a unilateral cleft lip and no nasal deformity.