Billing code 42235: Palate repairMedicare rate & RVUs in Virginia
Surgical repair of a palatal defect, reported for operative reconstruction of the palate rather than palate lengthening or prosthetic treatment.
CMS doesn’t publish an office rate for 42235 in Virginia.
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 42235 covers
This service is an operation to repair a defect of the palate, restoring continuity of the involved palatal tissues. It is performed by an appropriately trained surgeon, commonly an oral and maxillofacial surgeon or plastic surgeon, in an operating room. The clinical record should identify the defect, its location and cause, and the repair performed. Residual defects after cleft-palate treatment and acquired palatal defects are examples of situations in which a surgeon may consider a repair procedure; the documented operation determines the applicable code.
Report 42235 for the palatal repair actually performed, not simply because a patient has a history of cleft palate. Distinguish repair from cleft-palate reconstruction, palate lengthening, and preparation or insertion of a palatal prosthesis. The operative report should describe the defect and the surgical work. CMS assigns a 90-day global period, including the day-before preoperative visit and related postoperative care. When multiple procedures are performed in the same session, the highest-valued procedure is paid in full and other procedures are subject to the standard multiple-procedure reduction. Assistant-at-surgery payment may be made; co-surgeons and team surgery are not permitted. Modifier 50 is inappropriate for this code.
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 42235 pays more and less in Virginia
| Payment locality | Office | Facility |
|---|---|---|
| Dc + Md/Va Suburbs | Unavailable | $777.68 |
| Virginia | Unavailable | $671.89 |
How the 42235 rate is calculated
Each of 42235’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 · 42235
RVUs × geographic indexes × conversion factor
Work7.81
7.81 RVUs× 1.000 GPCI
Practice expense11.70
11.70 RVUs× 1.000 GPCI
Malpractice1.14
1.14 RVUs× 1.000 GPCI
Adjusted RVUs
20.6500
Conversion factor
$33.4009
Medicare rate
$689.73
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 42235
42235 has a 90-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42235
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 · 42235
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
42235 without 51 · national facility
$689.73
Palate repair
42235-51 · Second procedure: 50%
$344.87
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%).
42235 compared with similar codes
Compare codes · National
5 codes, side by side
How to choose
- 42200Cleft palate repair
- 42200 represents cleft-palate palatoplasty. Choose 42235 when the documented service is palatal repair rather than that reconstructive palatoplasty.
- 42226Palate lengthening
- 42226 describes secondary palate lengthening. 42235 is for repair, not lengthening.
- 42227Palate lengthening
- 42227 is secondary palate lengthening by local tissue rearrangement; use 42235 for the separately defined palatal repair service.
- 42281Palate prosthesis
- 42281 covers insertion of a palatal prosthesis, while 42235 describes an operative repair.
42235 billing questions
How is palate repair distinguished from cleft-palate reconstruction?
Use the code that matches the operation documented. 42235 represents palatal repair; the cleft-palate reconstruction codes describe a different reconstructive service.
Is this code for palate lengthening?
No. Palate lengthening procedures, including secondary lengthening, are represented by separate codes such as 42226 and 42227.
Does the service include postoperative visits?
Yes. The 90-day global period includes the day-before preoperative visit and related postoperative care.
Can an assistant surgeon be reported?
CMS indicates that assistant-at-surgery payment may be made for this code. Co-surgeon and team-surgery payment is not permitted.
Should modifier 50 be appended for bilateral work?
No. CMS identifies bilateral adjustment as inappropriate for this code.
What happens when another procedure is performed in the same session?
Under the standard multiple-procedure rule, the highest-valued procedure is paid in full and other procedures are reduced to 50% when performed in the same session.
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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