No office rate
42200 is for a limited primary or secondary cleft palate repair. Use 42215 when the secondary repair includes the muscle repositioning specified for that code.
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CMS RVU26D · Effective 2026-10-01
42215 Cleft palate repair Medicare reimbursement rates in Massachusetts
Reports secondary cleft palate reconstruction with repositioning of palatal muscles, commonly performed to improve palatal function after an earlier repair. Compare 42215 office and facility rates across CMS payment localities in Massachusetts.
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 42215 in Massachusetts?
Massachusetts has 2 payment localities in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the 2 payment areas shown below, using the same CMS release.
Office / nonfacility
No supported rate
Facility setting
$658.60–$713.51
2 of 2 localities have a supported rate.
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.
Palatal surgery
About 42215: Secondary cleft palate repair with muscle repositioning
Reports secondary cleft palate reconstruction with repositioning of palatal muscles, commonly performed to improve palatal function after an earlier repair.
This operation repairs a previously treated cleft palate and repositions the palatal muscles as part of the reconstruction. It may be performed for a patient with persistent palatal dysfunction after an earlier cleft repair. Plastic surgeons, otolaryngologists, and oral and maxillofacial surgeons may perform the procedure, typically in an operating room. The operative report should identify the prior repair and document the muscle repositioning and reconstructive work performed.
Report 42215 when the documented procedure matches this secondary repair with muscle repositioning, rather than selecting a code based only on the diagnosis of cleft palate. The 90-day global period includes 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 the others are subject to the standard multiple-procedure reduction. Modifier 50 is inappropriate for this code. An assistant at surgery may be paid; co-surgeons and team surgery are not permitted.
CMS billing rules for 42215
- 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 RVU8.77 · 45%
- Practice expense (office) RVU9.03 · 46%
- Malpractice RVU1.63 · 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.
42215 compared with similar codes
Office rates for Massachusetts, from the same CMS release.
No office rate
42205 describes an extensive primary or secondary repair. 42215 identifies secondary reconstruction with muscle repositioning rather than extent alone.
No office rate
42210 includes bone grafting to the alveolus. 42215 is the secondary repair with muscle repositioning; select based on the procedure actually documented.
No office rate
42220 involves a pharyngeal flap in secondary cleft palate repair. 42215 describes secondary repair with muscle repositioning.
Compare 42215 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.
2 of 2 payment localities
Metropolitan Boston →
Office / nonfacility
Unavailable
Facility
$713.51
Rest Of Massachusetts →
Office / nonfacility
Unavailable
Facility
$658.60
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42215 billing questions
How does 42215 differ from 42200 or 42205?
42215 identifies a secondary cleft palate repair with muscle repositioning. Choose between 42200 and 42205 based on the limited or extensive repair described by those codes, not simply because the patient has a cleft palate.
How does 42215 differ from 42220?
42215 describes secondary repair with muscle repositioning. 42220 describes a secondary repair involving a pharyngeal flap, so the documented operative technique determines the choice.
What documentation supports reporting 42215?
The operative report should establish that this is a secondary cleft palate reconstruction and describe repositioning of the palatal muscles. A diagnosis of cleft palate alone does not establish the specific procedure.
Does the 90-day global period include related postoperative care?
Yes. The global period includes the day-before preoperative visit and 90 days of related postoperative care.
Can 42215 be billed with modifier 50?
No. The CMS bilateral adjustment does not apply to this code, and modifier 50 is inappropriate.
Can an assistant or co-surgeon be reported?
An assistant at surgery may be paid. Co-surgeons and team surgery are not permitted under the CMS rules for this code.
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.
5,00542205,,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
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