Billing code 42200: Cleft palate repairMedicare rate & RVUs in Texas
Reports operative closure of a congenital cleft involving the soft palate, hard palate, or both, without alveolar ridge repair.
CMS doesn’t publish an office rate for 42200 in Texas.
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 42200 covers
Code 42200 describes surgical reconstruction to close a cleft in the soft palate, hard palate, or both. A plastic, craniofacial, oral and maxillofacial, or otolaryngology surgeon typically performs the operation under general anesthesia in a hospital or other surgical facility. The operative approach brings the separated palatal tissues together to restore continuity between the oral and nasal cavities.
Select this code when the documented repair is confined to the palate and does not include alveolar ridge closure or bone grafting there. The operative report should identify the cleft anatomy and the tissues repaired. CMS classifies the service as major surgery: the day-before preoperative visit and 90 days of related postoperative care are included. When multiple procedures occur in the same session, the highest-valued procedure is paid in full and other procedures are subject to the standard multiple procedure reduction. An assistant at surgery may be paid; co-surgeon and team-surgery payment are not permitted. Modifier 50 is inappropriate for this repair.
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.
Where 42200 pays more and less in Texas
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
8 of 8 payment localities
| Payment locality | Office | Facility |
|---|---|---|
| Austin | Unavailable | $855.68 |
| Beaumont | Unavailable | $805.04 |
| Brazoria | Unavailable | $826.06 |
| Dallas | Unavailable | $834.18 |
| Fort Worth | Unavailable | $831.58 |
| Galveston | Unavailable | $830.42 |
| Houston | Unavailable | $871.97 |
| Rest Of Texas | Unavailable | $817.06 |
How the 42200 rate is calculated
Each of 42200’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 · 42200
RVUs × geographic indexes × conversion factor
Work12.22
12.22 RVUs× 1.000 GPCI
Practice expense10.74
10.74 RVUs× 1.000 GPCI
Malpractice2.27
2.27 RVUs× 1.000 GPCI
Adjusted RVUs
25.2300
Conversion factor
$33.4009
Medicare rate
$842.70
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 42200
42200 has a 90-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42200
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 · 42200
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
42200 without 51 · national facility
$842.70
Cleft palate repair
42200-51 · Second procedure: 50%
$421.35
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%).
42200 compared with similar codes
Compare codes · National
5 codes, side by side
How to choose
- 42205Cleft palate revision
- Choose 42200 when reconstruction is confined to the soft and/or hard palate. Choose 42205 when the operation also includes soft-tissue closure of the alveolar ridge.
- 42210Cleft palate repair
- Choose 42210 when bone grafting to the alveolar ridge is part of the cleft palate reconstruction; 42200 is for palatal repair without that grafting.
- 42215Cleft palate repair
- 42215 describes secondary cleft palate surgery focused on lengthening the palate, rather than the palate closure represented by 42200.
- 42220Cleft palate repair
- 42220 is used for secondary revision of a cleft palate repair; 42200 represents reconstruction of the palate itself.
42200 billing questions
How is 42200 distinguished from other cleft palate reconstruction codes?
Use 42200 for repair confined to the soft and/or hard palate. A procedure that also closes the alveolar ridge or grafts bone there is represented by a different code.
Can 42200 be reported with alveolar ridge repair?
When alveolar ridge closure or bone grafting is part of the operation, select the code that represents that work rather than reporting 42200 for the same reconstruction.
Should modifier 50 be appended for a cleft on both sides?
No. Modifier 50 is inappropriate for 42200; the code describes the palatal reconstruction rather than a separately payable bilateral service.
What postoperative care is included in the global period?
The major-surgery global period includes the day-before preoperative visit and 90 days of related postoperative care.
Can an assistant surgeon be reported?
CMS permits payment for an assistant at surgery for 42200. Co-surgeon and team-surgery payment are not permitted.
What documentation supports reporting 42200?
Document the cleft's location and the palatal tissues reconstructed, and clarify whether the operation also involved the alveolar ridge or bone grafting.
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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