No office rate
42260 closes a fistula between the nose and lip. Choose a palate repair code when the documented defect and repair are in the palate.
On this page
CMS RVU26D · Effective 2026-10-01
42260 Fistula repair Medicare reimbursement rates in Pennsylvania
Repair of an abnormal passage between the nose and upper lip, reported when a surgeon closes the nose-to-lip fistula. Compare 42260 office and facility rates across CMS payment localities in Pennsylvania.
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 42260 in Pennsylvania?
Pennsylvania 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
$811.39–$887.40
2 of 2 localities have a supported rate.
Facility setting
$567.63–$610.97
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.
Oral and facial surgery
About 42260: Repair of a nose-to-lip fistula
Repair of an abnormal passage between the nose and upper lip, reported when a surgeon closes the nose-to-lip fistula.
A nose-to-lip fistula is an abnormal opening connecting nasal and lip tissues. This procedure closes that passage rather than reconstructing a cleft palate or repairing a defect within the palate. A plastic surgeon or oral and maxillofacial surgeon typically performs the repair in an operating room. The operative report should identify the fistula’s location and describe its closure.
Select 42260 for the nose-to-lip tract, not for an opening confined to the palate. The day-before preoperative visit and 90 days of related postoperative care are included in its major-surgery global period. If other procedures are performed in the same session, CMS pays the highest-valued procedure in full and other procedures at 50% under the standard multiple-procedure rule. Modifier 50 is inappropriate for this anatomy. An assistant at surgery may be paid; co-surgeon and team-surgery billing are not permitted.
CMS billing rules for 42260
- 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 RVU9.96 · 39%
- Practice expense (office) RVU14.12 · 55%
- Malpractice RVU1.45 · 6%
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.
42260 compared with similar codes
Office rates for Pennsylvania, from the same CMS release.
No office rate
42200 describes cleft-palate reconstruction. Choose 42260 when the documented operation specifically repairs a nose-to-lip fistula rather than reconstructing the palate.
Compare 42260 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 Philadelphia →
Office / nonfacility
$887.40
Facility
$610.97
Rest Of Pennsylvania →
Office / nonfacility
$811.39
Facility
$567.63
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42260 billing questions
How does 42260 differ from a palate repair?
Use 42260 when the repaired fistula connects the nose and lip. For a defect located in the palate, select the code that describes the palatal procedure performed.
What documentation supports 42260?
The operative report should locate the passage between the nose and lip and describe how the surgeon closed it.
Is postoperative care separately reported?
The 90-day global period includes related postoperative care and the day-before preoperative visit.
Can modifier 50 be used for this repair?
No. Modifier 50 is inappropriate for the nose-to-lip fistula repair described by 42260.
What happens if another procedure is performed in the same session?
The standard multiple-procedure rule pays the highest-valued procedure in full and other procedures at 50%.
Can another surgeon participate in the repair?
An assistant at surgery may be paid. CMS does not permit co-surgeon or team-surgery billing for 42260.
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.
5,01242226,,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
5,01442235,,Repair palate,A,,7.81,11.70,NA,11.70,,1.14,20.65,20.65,0,090,0.09,0.81,0.10,2,0,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,01542260,,Repair nose to lip fistula,A,,9.96,14.12,,6.17,,1.45,25.53,17.58,0,090,0.09,0.81,0.10,2,0,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,01642280,,Preparation palate mold,A,,1.55,3.77,,1.17,,0.22,5.54,2.94,0,010,0.10,0.80,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,01742281,,Insertion palate prosthesis,A,,1.93,5.03,,2.40,,0.27,7.23,4.60,0,010,0.10,0.80,0.10,2,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,01842299,,Unlisted px palate uvula,C,,0.00,0.00,,0.00,,0.00,0.00,0.00,0,YYY,0.00,0.00,0.00,2,0,2,1,1,9,,33.4009,09,0,99,0.00,0.00,0.00