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00102
Anesthesia for Plastic Repair of Cleft Lip Billing & Coding Guide
Code Description
CPT code 00102 describes anesthesia services provided for plastic repair of a cleft lip. The anesthesia provider performs the pre-anesthesia evaluation, administers anesthesia, continuously monitors the patient throughout the procedure, manages the airway, and oversees recovery until care is safely transferred.
This code is most commonly reported for congenital cleft lip repair performed in infants and children, although it may also apply to reconstructive procedures in older patients. Reimbursement is based on anesthesia base units, documented anesthesia time, applicable ASA physical status modifiers, and any qualifying circumstances recognized by the payer.
When to Use CPT 00102
Report 00102 when anesthesia services are provided for surgical repair or reconstruction of a cleft lip. The anesthesia record should document continuous care from induction through transfer to postoperative recovery.
When Not to Use CPT 00102
Do not report 00102 when another anesthesia CPT code more accurately describes the surgical procedure. This code should not be reported by the operating surgeon or for moderate sedation services reported separately under CPT guidelines.
Documentation Requirements
Documentation should include the pre-anesthesia evaluation, anesthesia start and stop times, ASA physical status, airway management, medications administered, physiologic monitoring, patient response throughout the procedure, and the post-anesthesia assessment. The operative report should support that anesthesia was provided for cleft lip repair.
Documentation Checklist
✔ Medical necessity documented
✔ Cleft lip repair documented
✔ Pre-anesthesia evaluation completed
✔ Anesthesia start and stop times documented
✔ ASA physical status documented
✔ Complete anesthesia record maintained
Billing Examples
Example 1
An anesthesiologist administers general anesthesia for an infant undergoing primary unilateral cleft lip repair. Report CPT code 00102 for the anesthesia service.
Example 2
A child undergoes revision cleft lip reconstruction under general anesthesia. The anesthesia provider documents the complete anesthesia record and reports CPT code 00102.
Base Units & Reimbursement
Anesthesia reimbursement for CPT 00102 is determined using base units, anesthesia time units, and the payer's conversion factor. Additional reimbursement may be available when qualifying circumstances are documented and payer requirements are met.
Accurate documentation of anesthesia start and stop times, the patient's ASA physical status, and all anesthesia services performed is essential for proper reimbursement.
Coding & Billing Tips
Document Accurate Anesthesia Time
Record anesthesia start and stop times accurately, as anesthesia time directly affects reimbursement.
Verify the Surgical Procedure
Confirm the surgical procedure is a cleft lip repair before reporting CPT code 00102.
Maintain Complete Documentation
Ensure the anesthesia record includes the pre-anesthesia evaluation, airway management, monitoring, medications administered, and postoperative assessment.
Common Billing Mistakes
Reporting the Wrong Anesthesia Code
Verify the surgical procedure corresponds to CPT code 00102 before submitting the claim.
Incomplete Time Documentation
Failure to accurately document anesthesia start and stop times may reduce reimbursement or result in claim denial.
Incomplete Anesthesia Record
Missing documentation of ASA status, monitoring, medications, or postoperative evaluation may delay payment.
Applicable ICD-10-CM Diagnosis Codes
Diagnosis codes should accurately reflect the documented condition and support medical necessity. The examples below are not all-inclusive.
Q36.9 – Cleft Lip, Unspecified
This diagnosis may support medical necessity when anesthesia is provided for surgical repair of a cleft lip. Documentation should support the diagnosis and planned operative procedure.
Q36.0 – Cleft Lip, Bilateral
This diagnosis may support medical necessity when anesthesia is required for bilateral cleft lip reconstruction. Documentation should describe the congenital defect and planned repair.
Q36.1 – Cleft Lip, Median
This diagnosis may support medical necessity when anesthesia is provided for surgical correction of a median cleft lip. Documentation should identify the specific congenital anomaly and operative treatment.
Related Codes
00100 – Anesthesia for Procedures on Salivary Glands, Including Biopsy
Report 00100 when anesthesia is provided for salivary gland procedures rather than cleft lip repair.
00103 – Anesthesia for Procedures on Nose and Accessory Sinuses
00103 describes anesthesia services for nasal and sinus procedures requiring a different anesthesia CPT code.
00104 – Anesthesia for Electroconvulsive Therapy
00104 is reported for anesthesia services provided during electroconvulsive therapy rather than reconstructive surgery.
Frequently Asked Questions
How is CPT code 00102 reimbursed?
Reimbursement is calculated using anesthesia base units, documented anesthesia time, the payer's conversion factor, and any applicable payment adjustments.
Does CPT code 00102 include anesthesia time?
Yes. Accurate anesthesia start and stop times are required because anesthesia time is included in reimbursement calculations.
Can a CRNA report CPT code 00102?
Yes. CRNAs may report CPT code 00102 when billing under applicable Medicare and commercial payer guidelines.
Is an ASA physical status modifier required?
Most payers require an ASA physical status modifier to reflect the patient's condition during anesthesia.
Can qualifying circumstance codes be reported with CPT 00102?
Yes. Qualifying circumstance codes may be reported when documentation supports additional complexity and payer requirements are satisfied.
Category
CPT
Reimbursement
Hospital & ASC
Base Units + Time Units
Description
Code Type
Code
00102
Plastic repair of cleft lip
Anesthesia
Common Setting
