Outpatient Facility Coding Alert

Question: How should I code an operative note note that involves the surgeon performing a partial flap takedown as part of a revision of a pharyngeal flap procedure performed two years prior?

Montana Subscriber

Answer: The physician may only perform a palatoplasty with attachment of a pharyngeal flap once; therefore, code 42225 (Palatoplasty for cleft palate; attachment pharyngeal flap) is out of the question. Furthermore, the October 2019 issue of CPT^® Assistant covers this topic, in which it recommends that you should instead report 42950 (Pharyngoplasty (plastic or reconstructive operation on pharynx)) for the revision “because the flap was created in a previous procedure.” 

---