Billing code 42225: Cleft palate repairMedicare rate & RVUs in Delaware
Reports secondary cleft palate reconstruction that lengthens the palate, including a pharyngeal flap when performed as part of the repair.
CMS doesn’t publish an office rate for 42225 in Delaware.
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 9 sections
What 42225 covers
This operation addresses a previously repaired cleft palate when additional palatal length is needed, often to improve separation of the oral and nasal cavities and speech-related function. A plastic, oral and maxillofacial, or other surgeon experienced in cleft and craniofacial surgery typically performs it in an operating room. A pharyngeal flap is a recognized example of a secondary lengthening approach associated with this code.
Select the code when the operative report supports secondary cleft-palate reconstruction involving lengthening, rather than an initial repair or a different palate-lengthening service. Document the prior cleft repair, the functional or anatomic problem, the technique, and the structures treated. Medicare includes the day-before preoperative visit and 90 days of related postoperative care in the major-surgery global period. For multiple procedures in one session, the highest-valued procedure is paid in full and other procedures are subject to the standard 50% reduction. Modifier 50 is inappropriate; an assistant at surgery may be paid, but 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.
42225 in Delaware
| Payment locality | Office | Facility |
|---|---|---|
| Delaware | Unavailable | $957.84 |
How the 42225 rate is calculated
Each of 42225’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 · 42225
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 9.53Practice expense 17.73Malpractice 1.76
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 42225
42225 has a 90-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42225
Cleft palate repair
| Rule | CMS value | What it means |
|---|---|---|
| Global period | 090 | Major surgery: the day before, the day of, and 90 days after are included. |
| Multiple procedures | 2 | Standard reduction: highest-valued procedure at 100%, others at 50%. |
| Bilateral (modifier 50) | 0 | The 150% bilateral adjustment doesn’t apply. |
| Assistant at surgery (80/81/82/AS) | 2 | Paid. |
| Co-surgeons (62) | 0 | Not permitted. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 0 | Physician service: no professional/technical split. |
| Split (54/55/56) | 0.09/0.81/0.10 | Share of the payment for pre-op, the procedure itself, and post-op care. |
Global surgery period · 42225
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.
Pre-op dayGlobal period
What modifiers do to the payment
Modifier 51 · payment effect
With and without the modifier
42225 without 51 · national facility
$969.29
Cleft palate repair
42225-51 · Second procedure: 50%
$484.65
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%).
42225 compared with similar codes
Compare codes
42225 vs 42200 vs 42205 vs 42226: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 42200Cleft palate repair
- Use 42200 for the specified soft- and/or hard-palate cleft repair. This code is for secondary cleft-palate reconstruction involving lengthening.
- 42205Cleft palate revision
- Use 42205 when the documented cleft-palate operation is a major revision; use this code when the service is a secondary lengthening procedure.
- 42226Palate lengthening
- 42226 is a palate-lengthening code associated with closure of nasopharyngeal incompetence, with or without fistula closure. This code is specific to secondary lengthening in cleft-palate reconstruction.
42225 billing questions
What documentation supports reporting this code?
The operative report should establish the prior cleft repair, the reason further lengthening is needed, and the procedure and tissues addressed. Document the technique, including a pharyngeal flap when used.
Are routine postoperative visits separately reported?
Related postoperative care during the 90-day global period is included. The day-before preoperative visit is also included.
Should modifier 50 be appended for bilateral work?
No. The code's descriptor and anatomy make a bilateral adjustment inappropriate.
Can an assistant or another surgeon be reported?
Medicare may pay for an assistant at surgery. Co-surgeons and team surgery are not permitted for this code.
What happens when other procedures are performed in the same session?
The highest-valued procedure is paid in full, and other procedures are subject to the standard multiple-procedure reduction. The operative record should distinguish the services performed.
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
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