No office rate
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.
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CMS RVU26D · Effective 2026-10-01
42220 Cleft palate repair Medicare reimbursement rates in Colorado
Reports secondary cleft palate surgery that reconstructs palatal muscle, often to address persistent velopharyngeal dysfunction after an earlier repair. Compare 42220 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 42220 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
$549.54
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.
Cleft palate surgery
About 42220: Secondary cleft palate muscle reconstruction
Reports secondary cleft palate surgery that reconstructs palatal muscle, often to address persistent velopharyngeal dysfunction after an earlier repair.
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.
CMS billing rules for 42220
- 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 RVU6.98 · 43%
- Practice expense (office) RVU7.87 · 49%
- Malpractice RVU1.30 · 8%
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.
42220 compared with similar codes
Office rates for Colorado, from the same CMS release.
No office rate
42215 represents secondary cleft palate repair with extensive reconstruction. 42220 is distinguished by reconstruction of palatal muscle.
No office rate
42200 describes cleft palate repair with soft-tissue closure of the alveolar ridge, rather than secondary muscle reconstruction.
Compare 42220 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
$549.54
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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 42220 in Colorado.
PPRRVU2026_Oct_nonQPP.csv
5,010
- Code
- 42220
- Physician work
- 6.98
- Practice expense
- 7.87
- Malpractice
- 1.30
GPCI2026.csv
37
- Locality
- Colorado
- Physician work
- 1.012
- Practice expense
- 1.064
- Malpractice
- 0.781
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 6.98 | × 1.012 | 7.0638 |
| Practice expense | 7.87 | × 1.064 | 8.3737 |
| Malpractice | 1.30 | × 0.781 | 1.0153 |
| Total RVUs | 16.4527 | ||
| Conversion factor | × 33.4009 | ||
Facility rate, Colorado$549.54
Explore RVUs, geographic factors and the full formula
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 6.98 | 1.012 |
| Practice expense | 7.87 | 1.064 |
| Malpractice | 1.3 | 0.781 |
(6.98 × 1.012 + 7.87 × 1.064 + 1.3 × 0.781) × $33.4009 = $549.54
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.
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 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.
5,00742210,,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
5,00842215,,Reconstruct cleft palate,A,,8.77,9.03,NA,9.03,,1.63,19.43,19.43,0,090,0.09,0.81,0.10,2,0,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,0094221F,,Diuretic 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
5,01042220,,Reconstruct cleft palate,A,,6.98,7.87,NA,7.87,,1.30,16.15,16.15,0,090,0.09,0.81,0.10,2,0,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,01142225,,Reconstruct cleft palate,A,,9.53,17.73,NA,17.73,,1.76,29.02,29.02,0,090,0.09,0.81,0.10,2,0,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,01242226,,Lengthening of palate,A,,10.09,13.43,NA,13.43,,1.47,24.99,24.99,0,090,0.09,0.81,0.10,2,0,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,01342227,,Lengthening of palate,A,,9.65,12.15,NA,12.15,,1.40,23.20,23.20,0,090,0.09,0.81,0.10,2,0,2,0,0,9,,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