No office rate
Use 42200 for palatoplasty limited to the soft and/or hard palate. 42205 identifies a major revision of a previous cleft palate repair.
On this page
CMS RVU26D · Effective 2026-10-01
42205 Cleft palate revision Medicare reimbursement rates in Rhode Island
Reports major reconstructive revision of a previously repaired cleft palate when the operative work exceeds routine palatoplasty. Compare 42205 office and facility rates across CMS payment localities in Rhode Island.
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 42205 in Rhode Island?
Rhode Island 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
$878.83
1 of 1 localities have a supported rate.
Payment area: Rhode Island
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 42205: Major revision of cleft palate repair
Reports major reconstructive revision of a previously repaired cleft palate when the operative work exceeds routine palatoplasty.
Code 42205 represents major revision of a previously repaired cleft palate, rather than routine initial closure. A craniofacial or plastic surgeon, and sometimes an otolaryngologist with cleft palate expertise, performs the reconstruction in an operating room. The operative report should identify the prior repair, the palatal anatomy revised, and the extent of reconstructive work supporting a major revision.
Report the service for the major revision, not for routine repair alone. CMS assigns a 90-day global period: the day-before preoperative visit and related postoperative care during the 90 days are included. If another procedure subject to multiple-procedure reduction is performed in the same session, the highest-valued procedure is paid in full and the others at 50%. 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 42205
- 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 RVU13.32 · 51%
- Practice expense (office) RVU10.19 · 39%
- Malpractice RVU2.48 · 10%
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.
42205 compared with similar codes
Office rates for Rhode Island, from the same CMS release.
No office rate
42210 describes cleft palate repair with alveolar ridge closure and bone grafting. Choose based on that specified procedure rather than the major-revision work represented by 42205.
No office rate
42215 is a secondary cleft palate repair that includes a pharyngeal flap. 42205 represents major revision without that specific procedure defining the code.
Compare 42205 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
Rhode Island →
Office / nonfacility
Unavailable
Facility
$878.83
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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 42205 in Rhode Island.
PPRRVU2026_Oct_nonQPP.csv
5,005
- Code
- 42205
- Physician work
- 13.32
- Practice expense
- 10.19
- Malpractice
- 2.48
GPCI2026.csv
92
- Locality
- Rhode Island
- Physician work
- 1.019
- Practice expense
- 1.033
- Malpractice
- 0.892
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 13.32 | × 1.019 | 13.5731 |
| Practice expense | 10.19 | × 1.033 | 10.5263 |
| Malpractice | 2.48 | × 0.892 | 2.2122 |
| Total RVUs | 26.3115 | ||
| Conversion factor | × 33.4009 | ||
Facility rate, Rhode Island$878.83
Explore RVUs, geographic factors and the full formula
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 13.32 | 1.019 |
| Practice expense | 10.19 | 1.033 |
| Malpractice | 2.48 | 0.892 |
(13.32 × 1.019 + 10.19 × 1.033 + 2.48 × 0.892) × $33.4009 = $878.83
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.
42205 billing questions
How does 42205 differ from 42200?
42205 is for a major revision of a prior cleft palate repair. Use 42200 for palatoplasty limited to the soft and/or hard palate without the major-revision distinction.
What documentation supports reporting 42205?
Document the prior cleft repair, the residual or recurrent anatomy being revised, and the operative work performed. The record should support why this was a major revision rather than routine palatoplasty.
Is routine postoperative care separately reported?
Related postoperative care during the 90-day global period is included, as is the day-before preoperative visit.
Can modifier 50 be appended?
No. CMS identifies bilateral adjustment as inappropriate for this code.
Can an assistant or another surgeon be reported?
An assistant at surgery may be paid. Co-surgeons and team surgery are not permitted.
How are other procedures in the same session paid?
Under the standard multiple-procedure reduction, the highest-valued procedure is paid in full and other procedures subject to the reduction are paid at 50%.
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.
5,00242180,,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
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
8912502,PA,01,METROPOLITAN PHILADELPHIA,1.018,1.041,1.193
9012502,PA,99,REST OF PENNSYLVANIA,1.000,0.918,0.945
9109202,PR,20,PUERTO RICO,1.000,1.011,0.985
9214412,RI,01,RHODE ISLAND,1.019,1.033,0.892
9311202,SC,01,SOUTH CAROLINA,1.000,0.924,0.850
9403402,SD,02,SOUTH DAKOTA**,1.000,1.000,0.336
9510312,TN,35,TENNESSEE,1.000,0.909,0.537