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Billing code 42220: Cleft palate repairMedicare rate & RVUs

Reports secondary cleft palate surgery that reconstructs palatal muscle, often to address persistent velopharyngeal dysfunction after an earlier repair.

CMS RVU26DEffective Oct 1, 2026109 payment localities

Medicare pays $539.42 for 42220 nationally in a facility.

Medicare rate · 42220

Cleft palate repair

Swap in your local Medicare rate.

Work RVUs
6.98
Total RVUs
16.15
Global days
090

National rate · 2026

$539.42

Facility setting, before claim adjustments.

See every locality for 42220 → · Billed by an NP, PA or therapist? →

Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.

On this page 10 sections
  1. Medicare rate
  2. What 42220 covers
  3. By payment locality
  4. Rate map
  5. How it’s calculated
  6. Payment rules
  7. Similar codes
  8. Related codes
  9. Billing questions
  10. Sources

What 42220 covers

This service is a secondary operation on a previously repaired cleft palate, with dissection and reconstruction of palatal muscle, commonly the levator muscle sling. Cleft and craniofacial surgeons typically perform it in an operating room. A common clinical context is persistent velopharyngeal dysfunction, such as hypernasal speech, after an earlier palate repair; the operative plan must include muscle reconstruction rather than only local tissue rearrangement or palate lengthening.

Report the code when the operative record supports secondary cleft palate reconstruction with muscle work. Document the prior repair, the muscle anatomy addressed, and the reconstruction performed. CMS assigns a 90-day global period, including the day-before preoperative visit and 90 days of related postoperative care. When multiple procedures are performed in the same session, the highest-valued procedure is paid in full and other procedures are subject to the standard 50% reduction. The operation is not billed bilaterally with modifier 50. An assistant at surgery may be paid; co-surgeons and team surgery are not permitted.

This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.

Where 42220 pays more and less

The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.

109 of 109 payment localities

42220 office and facility rates by payment locality
Payment localityOfficeFacility
AlabamaUnavailable$487.72
Alaska*Unavailable$653.58
ArizonaUnavailable$525.02
ArkansasUnavailable$481.30
AtlantaUnavailable$553.06
AustinUnavailable$550.19
BakersfieldUnavailable$552.11
Baltimore/Surr. CntysUnavailable$572.63
BeaumontUnavailable$512.68
BrazoriaUnavailable$529.37

42220 rates by state

Office rate range in each state. Select a state to see its payment localities.

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Local rates. Clear comparisons.

Hover or focus a tile to see its rate range. Select it to open the state’s fee schedule.

View every state and territory as a table
42220 office rate range by state
State / territoryOffice rate rangeLocalities
AKNo published base rate1
ALNo published base rate1
ARNo published base rate1
AZNo published base rate1
CANo published base rate29
CONo published base rate1
CTNo published base rate1
DCNo published base rate1
DENo published base rate1
FLNo published base rate3
GANo published base rate2
GUNo published base rate1
HINo published base rate1
IANo published base rate1
IDNo published base rate1
ILNo published base rate4
INNo published base rate1
KSNo published base rate1
KYNo published base rate1
LANo published base rate2
MANo published base rate2
MDNo published base rate3
MENo published base rate2
MINo published base rate2
MNNo published base rate1
MONo published base rate3
MSNo published base rate1
MTNo published base rate1
NCNo published base rate1
NDNo published base rate1
NENo published base rate1
NHNo published base rate1
NJNo published base rate2
NMNo published base rate1
NVNo published base rate1
NYNo published base rate5
OHNo published base rate1
OKNo published base rate1
ORNo published base rate2
PANo published base rate2
PRNo published base rate1
RINo published base rate1
SCNo published base rate1
SDNo published base rate1
TNNo published base rate1
TXNo published base rate8
UTNo published base rate1
VANo published base rate2
VINo published base rate1
VTNo published base rate1
WANo published base rate2
WINo published base rate1
WVNo published base rate1
WYNo published base rate1

How the 42220 rate is calculated

Each of 42220’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.

How the rate is built · 42220

RVUs × geographic indexes × conversion factor

Swap in your local Medicare rate.

Work 6.98Practice expense 7.87Malpractice 1.30

16.1500 adjusted RVUs×$33.4009 conversion factor=$539.42

All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.

Payment rules and modifiers for 42220

42220 has a 90-day global period: related visits in that window are included in the surgery payment.

CMS payment indicators · 42220

Cleft palate repair

RuleCMS valueWhat it means
Global period090Major surgery: the day before, the day of, and 90 days after are included.
Multiple procedures2Standard reduction: highest-valued procedure at 100%, others at 50%.
Bilateral (modifier 50)0The 150% bilateral adjustment doesn’t apply.
Assistant at surgery (80/81/82/AS)2Paid.
Co-surgeons (62)0Not permitted.
Team surgery (66)0Not permitted.
Professional/technical0Physician service: no professional/technical split.
Split (54/55/56)0.09/0.81/0.10Share of the payment for pre-op, the procedure itself, and post-op care.

Global surgery period · 42220

Cleft palate repair

90-day global period ends

Dec 30, 2026

Covers Sep 30, 2026 through Dec 30, 2026 (92 days, including the day before surgery).

Visit on Oct 31, 2026

Day 30 of the 90-day post-op period: related follow-up care is included in the surgical payment.

  • 24 Unrelated E/M visit by the same physician
  • 79 Unrelated procedure (starts its own global period)
  • 58 Staged, more extensive, or therapy procedure that was planned
  • 78 Unplanned return to the operating room for a related complication
SurgeryVisit
Sep 23, 2026Jan 10, 2027

Pre-op dayGlobal period

What modifiers do to the payment

Modifier 51 · payment effect

With and without the modifier

42220 without 51 · national facility

$539.42

Cleft palate repair

42220-51 · Second procedure: 50%

$269.71

When this isn’t the highest-valued procedure in the session, Medicare pays 50% of its fee schedule amount (the highest is paid at 100%).

When to use modifier 51

42220 compared with similar codes

Compare codes

42220 vs 42210 vs 42215 vs 42200: national Medicare rates

Swap in your local Medicare rate.

  • 42220
    Cleft palate repair · 6.98 wRVU
    —
  • 42210
    Cleft palate repair · 14.65 wRVU
    —
  • 42215
    Cleft palate repair · 8.77 wRVU
    —
  • 42200
    Cleft palate repair · 12.22 wRVU
    —

How to choose

42210Cleft palate repair
Choose 42210 for secondary repair by local flap when palatal muscle reconstruction is not the defining work. Choose 42220 when the operation reconstructs palatal muscle.
42215Cleft palate repair
42215 represents secondary cleft palate repair with extensive reconstruction. 42220 is distinguished by reconstruction of palatal muscle.
42200Cleft palate repair
42200 describes cleft palate repair with soft-tissue closure of the alveolar ridge, rather than secondary muscle reconstruction.

Codes related to 42220

Related codes aren’t interchangeable: bill the code that matches the service performed.

Codes related to 42220
CodeHow it relatesNational office range
Same family
42200Cleft palate repairCleft palate repair involving soft-tissue closure of the alveolar ridge.No office rate
42205Cleft palate revisionCleft palate repair involving bone grafting at the alveolar ridge.No office rate
42210Cleft palate repairSecondary cleft palate repair using a local flap.No office rate
42215Cleft palate repairSecondary cleft palate repair involving extensive reconstruction.No office rate

42220 billing questions

How is 42220 different from a secondary local-flap repair?

Use 42220 when the secondary cleft palate operation includes reconstruction of palatal muscle. A repair limited to local flap work is represented by 42210.

How does 42220 differ from 42215?

42220 identifies secondary reconstruction involving palatal muscle. 42215 is the neighboring code for secondary repair involving extensive reconstruction; the operative technique and documented work determine the selection.

Are routine postoperative visits separately reported?

Related postoperative care for 90 days is included in the global period, as is the day-before preoperative visit.

Can 42220 be reported with another procedure performed in the same session?

When multiple procedures are performed in the same session, CMS pays the highest-valued procedure in full and applies the standard 50% reduction to the others.

Can modifier 50 or a co-surgeon arrangement be used?

No. The service is not subject to bilateral adjustment, and CMS does not permit co-surgeons or team surgery for this code. An assistant at surgery may be paid.

Where these rates come from

FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.

CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027

Show the CMS file lines behind this rate
RVUs for 42220PPRRVU2026_Oct_nonQPP.csv, line 5,010 (RVU26D)

Open CMS sourceHow we calculate rates

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