No office rate
Choose 42200 when reconstruction is confined to the soft and/or hard palate. Choose 42205 when the operation also includes soft-tissue closure of the alveolar ridge.
On this page
CMS RVU26D · Effective 2026-10-01
42200 Cleft palate repair Medicare reimbursement rates in Colorado
Reports operative closure of a congenital cleft involving the soft palate, hard palate, or both, without alveolar ridge repair. Compare 42200 office and facility rates across CMS payment localities in Colorado.
Amounts below use the non-QP conversion factor for participating physicians. These are base physician payments before claim-level adjustments, not patient costs or total hospital charges.
What does Medicare pay for 42200 in Colorado?
Colorado has 1 payment locality in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the payment area shown below, using the same CMS release.
Office / nonfacility
No supported rate
Facility setting
$853.96
1 of 1 localities have a supported rate.
Payment area: Colorado
One mapped payment locality.
These are locality ranges, not averages or address-specific quotes. A facility-setting amount covers the physician service; it does not include a hospital’s separate bill. Choose a locality below to inspect its calculation, compare other payment areas, or price a percentage of Medicare.
Craniofacial surgery
About 42200: Cleft palate reconstruction
Reports operative closure of a congenital cleft involving the soft palate, hard palate, or both, without alveolar ridge repair.
Code 42200 describes surgical reconstruction to close a cleft in the soft palate, hard palate, or both. A plastic, craniofacial, oral and maxillofacial, or otolaryngology surgeon typically performs the operation under general anesthesia in a hospital or other surgical facility. The operative approach brings the separated palatal tissues together to restore continuity between the oral and nasal cavities.
Select this code when the documented repair is confined to the palate and does not include alveolar ridge closure or bone grafting there. The operative report should identify the cleft anatomy and the tissues repaired. CMS classifies the service as major surgery: the day-before preoperative visit and 90 days of related postoperative care are included. When multiple procedures occur in the same session, the highest-valued procedure is paid in full and other procedures are subject to the standard multiple procedure reduction. An assistant at surgery may be paid; co-surgeon and team-surgery payment are not permitted. Modifier 50 is inappropriate for this repair.
CMS billing rules for 42200
- Global period
- Major surgery with a 90-day global period: the day-before preoperative visit and 90 days of related postoperative care are included.
- Multiple procedures
- Standard multiple procedure reduction: the highest-valued procedure is paid in full and others at 50% when performed in the same session.
- Bilateral procedures
- Bilateral adjustment does not apply; the descriptor or anatomy makes modifier 50 inappropriate.
- Assistant at surgery
- Assistant at surgery may be paid.
- Co-surgeons
- Co-surgeons not permitted.
- Team surgery
- Team surgery not permitted.
Where the value comes from
- Work RVU12.22 · 48%
- Practice expense (office) RVU10.74 · 43%
- Malpractice RVU2.27 · 9%
29
Medicare services in 2024 · #5687 by national volume
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.
42200 compared with similar codes
Office rates for Colorado, from the same CMS release.
No office rate
Choose 42210 when bone grafting to the alveolar ridge is part of the cleft palate reconstruction; 42200 is for palatal repair without that grafting.
No office rate
42215 describes secondary cleft palate surgery focused on lengthening the palate, rather than the palate closure represented by 42200.
No office rate
42220 is used for secondary revision of a cleft palate repair; 42200 represents reconstruction of the palate itself.
Compare 42200 by payment locality
Find the payment area for your service address, then open its rate page for calculation inputs, release history and the percentage-of-Medicare tool. A city may cross payment-area boundaries; the ZIP lookup above helps resolve the location.
1 of 1 payment localities
Colorado →
Office / nonfacility
Unavailable
Facility
$853.96
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How this local rate is calculated
Each RVU component is multiplied by its own geographic practice cost index (GPCI). The three adjusted components are added, then multiplied by the conversion factor. These are the inputs used for 42200 in Colorado.
PPRRVU2026_Oct_nonQPP.csv
5,004
- Code
- 42200
- Physician work
- 12.22
- Practice expense
- 10.74
- Malpractice
- 2.27
GPCI2026.csv
37
- Locality
- Colorado
- Physician work
- 1.012
- Practice expense
- 1.064
- Malpractice
- 0.781
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 12.22 | × 1.012 | 12.3666 |
| Practice expense | 10.74 | × 1.064 | 11.4274 |
| Malpractice | 2.27 | × 0.781 | 1.7729 |
| Total RVUs | 25.5669 | ||
| Conversion factor | × 33.4009 | ||
Facility rate, Colorado$853.96
Explore RVUs, geographic factors and the full formula
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 12.22 | 1.012 |
| Practice expense | 10.74 | 1.064 |
| Malpractice | 2.27 | 0.781 |
(12.22 × 1.012 + 10.74 × 1.064 + 2.27 × 0.781) × $33.4009 = $853.96
The office and facility calculations use their respective practice-expense RVUs. The facility amount here is the physician fee, not a separate hospital or facility bill.
42200 billing questions
How is 42200 distinguished from other cleft palate reconstruction codes?
Use 42200 for repair confined to the soft and/or hard palate. A procedure that also closes the alveolar ridge or grafts bone there is represented by a different code.
Can 42200 be reported with alveolar ridge repair?
When alveolar ridge closure or bone grafting is part of the operation, select the code that represents that work rather than reporting 42200 for the same reconstruction.
Should modifier 50 be appended for a cleft on both sides?
No. Modifier 50 is inappropriate for 42200; the code describes the palatal reconstruction rather than a separately payable bilateral service.
What postoperative care is included in the global period?
The major-surgery global period includes the day-before preoperative visit and 90 days of related postoperative care.
Can an assistant surgeon be reported?
CMS permits payment for an assistant at surgery for 42200. Co-surgeon and team-surgery payment are not permitted.
What documentation supports reporting 42200?
Document the cleft's location and the palatal tissues reconstructed, and clarify whether the operation also involved the alveolar ridge or bone grafting.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense, and malpractice RVUs, adjusted by each locality’s geographic indices and the applicable conversion factor. Unavailable or separately priced services are labeled rather than assigned a made-up amount.
Source: RVU26D. Effective 2026-10-01 through the day before 2027-01-01.
5,00142160,,Treatment mouth roof lesion,A,,1.80,4.94,,1.84,,0.22,6.96,3.86,0,010,0.10,0.80,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,00242180,,Repair lac palate<2 cm,A,,2.49,4.78,,2.20,,0.36,7.63,5.05,0,010,0.10,0.80,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,00342182,,Repair palate,A,,3.77,5.54,,2.51,,0.54,9.85,6.82,0,010,0.10,0.80,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,00442200,,Reconstruct cleft palate,A,,12.22,10.74,NA,10.74,,2.27,25.23,25.23,0,090,0.09,0.81,0.10,2,0,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,00542205,,Reconstruct cleft palate,A,,13.32,10.19,NA,10.19,,2.48,25.99,25.99,0,090,0.09,0.81,0.10,2,0,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,0064220F,,Digoxin thxpy for 6 mos/>,I,,0.00,0.00,,0.00,,0.00,0.00,0.00,9,XXX,0.00,0.00,0.00,9,9,9,9,9,9,,33.4009,09,0,99,0.00,0.00,0.00
5,00742210,,Reconstruct cleft palate,A,,14.65,11.68,NA,11.68,,2.72,29.05,29.05,0,090,0.09,0.81,0.10,2,0,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
3401112,CA,69,VISALIA,1.017,1.096,0.536
3501112,CA,70,YUBA CITY,1.017,1.096,0.536
3601112,CA,75,REST OF CALIFORNIA,1.017,1.096,0.536
3704112,CO,01,COLORADO,1.012,1.064,0.781
3813102,CT,00,CONNECTICUT,1.020,1.077,1.210
3912202,DC,01,DC + MD/VA SUBURBS,1.054,1.178,1.113
4012102,DE,01,DELAWARE,1.005,0.988,0.899