No office rate
42200 represents cleft-palate palatoplasty. Choose 42235 when the documented service is palatal repair rather than that reconstructive palatoplasty.
On this page
CMS RVU26D · Effective 2026-10-01
42235 Palate repair Medicare reimbursement rates in Wisconsin
Surgical repair of a palatal defect, reported for operative reconstruction of the palate rather than palate lengthening or prosthetic treatment. Compare 42235 office and facility rates across CMS payment localities in Wisconsin.
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 42235 in Wisconsin?
Wisconsin 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
$646.97
1 of 1 localities have a supported rate.
Payment area: Wisconsin
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.
Oral surgery
About 42235: Operative repair of the palate
Surgical repair of a palatal defect, reported for operative reconstruction of the palate rather than palate lengthening or prosthetic treatment.
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.
CMS billing rules for 42235
- 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 RVU7.81 · 38%
- Practice expense (office) RVU11.70 · 57%
- Malpractice RVU1.14 · 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.
42235 compared with similar codes
Office rates for Wisconsin, from the same CMS release.
No office rate
42226 describes secondary palate lengthening. 42235 is for repair, not lengthening.
No office rate
42227 is secondary palate lengthening by local tissue rearrangement; use 42235 for the separately defined palatal repair service.
$228.19
42281 covers insertion of a palatal prosthesis, while 42235 describes an operative repair.
Compare 42235 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
Wisconsin →
Office / nonfacility
Unavailable
Facility
$646.97
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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 42235 in Wisconsin.
PPRRVU2026_Oct_nonQPP.csv
5,014
- Code
- 42235
- Physician work
- 7.81
- Practice expense
- 11.70
- Malpractice
- 1.14
GPCI2026.csv
111
- Locality
- Wisconsin
- Physician work
- 1.000
- Practice expense
- 0.958
- Malpractice
- 0.308
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 7.81 | × 1.000 | 7.8100 |
| Practice expense | 11.70 | × 0.958 | 11.2086 |
| Malpractice | 1.14 | × 0.308 | 0.3511 |
| Total RVUs | 19.3697 | ||
| Conversion factor | × 33.4009 | ||
Facility rate, Wisconsin$646.97
Explore RVUs, geographic factors and the full formula
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 7.81 | 1 |
| Practice expense | 11.7 | 0.958 |
| Malpractice | 1.14 | 0.308 |
(7.81 × 1 + 11.7 × 0.958 + 1.14 × 0.308) × $33.4009 = $646.97
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.
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 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.
5,01142225,,Reconstruct cleft palate,A,,9.53,17.73,NA,17.73,,1.76,29.02,29.02,0,090,0.09,0.81,0.10,2,0,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,01242226,,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
10802402,WA,02,SEATTLE (KING CNTY),1.050,1.227,0.817
10902402,WA,99,REST OF WASHINGTON,1.013,1.053,0.761
11011402,WV,16,WEST VIRGINIA,1.000,0.869,1.431
11106302,WI,00,WISCONSIN,1.000,0.958,0.308
11203602,WY,21,WYOMING**,1.000,1.000,0.740
113"MAC Assignments as of November 22, 2023",,,,,,
114,,,,,,