Billing code 42260: Fistula repairMedicare rate & RVUs in Texas
Repair of an abnormal passage between the nose and upper lip, reported when a surgeon closes the nose-to-lip fistula.
Medicare pays $806.84–$875.22 for 42260 in the office in Texas, from Beaumont to Austin. Which amount applies depends on the service address.
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 42260 covers
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.
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 42260 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 payment localities
$806.84 to $875.22
8 of 8 payment localities
| Payment locality | Office | Facility |
|---|---|---|
| Austin | $875.22 | $594.28 |
| Beaumont | $806.84 | $565.20 |
| Brazoria | $840.49 | $577.34 |
| Dallas | $846.96 | $582.48 |
| Fort Worth | $842.87 | $581.05 |
| Galveston | $843.75 | $580.08 |
| Houston | $870.30 | $606.62 |
| Rest Of Texas | $823.97 | $571.98 |
How the 42260 rate is calculated
Each of 42260’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 · 42260
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 9.96Practice expense 14.12Malpractice 1.45
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 42260
42260 has a 90-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42260
Fistula 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 · 42260
Fistula 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
42260 without 51 · national office
$852.72
Fistula repair
42260-51 · Second procedure: 50%
$426.36
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%).
42260 compared with similar codes
Compare codes
42260 vs 42235 vs 42200: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 42235Palate repair
- 42260 closes a fistula between the nose and lip. Choose a palate repair code when the documented defect and repair are in the palate.
- 42200Cleft palate repair
- 42200 describes cleft-palate reconstruction. Choose 42260 when the documented operation specifically repairs a nose-to-lip fistula rather than reconstructing the palate.
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 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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