CPT 00102
Anesthesia for Plastic Repair of Cleft Lip Billing & Coding Guide
Code Description
CPT code 00102 is used for anesthesia services provided during plastic repair of a cleft lip. It is part of the anesthesia code range for procedures involving the head.
The anesthesia provider evaluates the patient before surgery, develops the anesthesia plan, administers anesthesia, continuously monitors the patient's physiologic status, and manages the patient throughout the anesthesia service.
Code selection should be based on the procedure performed. A diagnosis of cleft lip alone does not establish that CPT code 00102 is appropriate unless the patient undergoes a qualifying plastic repair procedure.
When to Use CPT 00102
Use CPT code 00102 when anesthesia is provided for a procedure involving plastic repair of a cleft lip.
Common situations may include:
Primary surgical repair of a cleft lip
Plastic repair of a unilateral cleft lip
Plastic repair of a bilateral cleft lip
Qualifying revision procedures involving plastic repair of a cleft lip
The operative report should clearly identify the cleft lip procedure performed. The anesthesia record should separately support the anesthesia service, monitoring, and reported anesthesia time.
When NOT to Use CPT Code 00102
Do not report CPT code 00102 when:
The procedure does not involve plastic repair of a cleft lip.
The patient has a cleft lip diagnosis but no qualifying repair is performed.
The procedure involves cleft palate repair rather than cleft lip repair.
Another anesthesia CPT code more accurately describes the procedure.
Documentation does not support the procedure associated with the anesthesia service.
Cleft palate and cleft lip repairs should not automatically be treated as the same procedure for anesthesia coding. Review the actual operative service before selecting the anesthesia code.
Documentation Requirements
Documentation should clearly support the anesthesia service and include:
Cleft lip repair procedure performed
Pre-anesthesia evaluation
Anesthesia plan
Medications and agents administered
Physiologic monitoring
Airway management when applicable
Anesthesia start and stop times
Patient response to anesthesia
ASA physical status when applicable
Post-anesthesia evaluation and transfer of care
The operative documentation should establish that plastic repair of the cleft lip was performed. The anesthesia record should support the anesthesia professional's involvement throughout the service.
When reimbursement is based partly on anesthesia time, start and stop times should be documented according to applicable payer requirements.
Documentation Checklist
Before submitting CPT code 00102, confirm that the medical record includes:
✓ Cleft lip repair procedure documented
✓ Medical necessity supported
✓ Pre-anesthesia evaluation completed
✓ Anesthesia plan documented
✓ Anesthesia start and stop times recorded
✓ Physiologic monitoring documented
✓ ASA physical status documented when applicable
✓ Airway management documented when applicable
✓ Post-anesthesia care documented
Examples
Example 1
An infant with a unilateral cleft lip undergoes primary plastic repair. The anesthesia provider completes the pre-anesthesia evaluation, administers anesthesia, continuously monitors the patient, and documents anesthesia time. CPT code 00102 is reported for the anesthesia service.
Example 2
A child with a bilateral cleft lip undergoes surgical plastic repair under general anesthesia. The anesthesia professional manages the patient's airway and physiologic status throughout the operation and maintains a complete anesthesia record. CPT code 00102 is reported.
Example 3
A patient undergoes a qualifying revision procedure involving plastic repair of a cleft lip. The anesthesia provider documents the pre-anesthesia assessment, anesthesia administration, monitoring, start and stop times, and postoperative transfer of care. CPT code 00102 may be appropriate when supported by the procedure performed.
Base Units & Reimbursement
Anesthesia reimbursement generally considers the anesthesia code's base units, documented anesthesia time, and the applicable payer conversion factor.
The basic anesthesia payment methodology generally considers:
Base Units + Time Units + Applicable Additional Units
The resulting units are then applied to the payer's anesthesia conversion factor. Actual reimbursement can also be affected by provider involvement, medical direction, qualifying circumstances, geographic adjustments, and payer-specific billing requirements.
Anesthesia start and stop times should be documented carefully because reported anesthesia time can directly affect reimbursement.
Coding & Billing Tips
Confirm that the operative report documents plastic repair of a cleft lip.
Do not confuse cleft lip repair with cleft palate repair.
Select the anesthesia code based on the procedure performed rather than the diagnosis alone.
Document anesthesia start and stop times accurately.
Link the appropriate ICD-10-CM diagnosis to the anesthesia service.
Document anesthesia provider involvement completely.
Review payer-specific anesthesia modifier, time, and reimbursement requirements before billing.
Common Billing Mistakes
Confusing cleft lip and cleft palate repair
CPT 00102 applies specifically to anesthesia for plastic repair of cleft lip. Review the operative report carefully when the patient has both a cleft lip and cleft palate.
Coding from the diagnosis alone
A cleft lip diagnosis does not automatically support CPT 00102. Documentation must show that a qualifying plastic repair procedure was performed.
Reporting inaccurate anesthesia time
Incorrect start or stop times can affect anesthesia time units and reimbursement. The anesthesia record should support the time reported on the claim.
Incomplete anesthesia documentation
Missing monitoring, medication, airway, or postoperative documentation can make it difficult to support the billed anesthesia service.
Using surgical procedure time as anesthesia time
Anesthesia time is not automatically identical to the duration of the surgical procedure. Report anesthesia time according to applicable anesthesia billing rules.
Selecting an unrelated head anesthesia code
CPT 00102 is procedure-specific. Other surgeries involving the head, face, eye, mouth, or salivary glands may require a different anesthesia code.
Common ICD-10-CM Codes
Q36.9 – Cleft Lip, Unilateral
May support medical necessity when a patient undergoes plastic repair of a documented unilateral cleft lip.
Q36.0 – Cleft Lip, Bilateral
May support medical necessity when anesthesia is provided during surgical repair of a documented bilateral cleft lip.
Q36.1 – Cleft Lip, Median
May apply when a documented median cleft lip requires plastic surgical repair under anesthesia.
Q37.9 – Cleft Palate with Cleft Lip, Unspecified
May apply when the patient has both cleft palate and cleft lip and the current procedure includes qualifying repair of the cleft lip.
Q37.8 – Unspecified Cleft Palate with Bilateral Cleft Lip
May be relevant when bilateral cleft lip occurs with cleft palate and the documented procedure includes repair of the lip.
Applicable Modifiers
Modifier AA identifies anesthesia services personally performed by an anesthesiologist. Report the modifier when it accurately reflects provider involvement and is required by the payer.
Modifier QX may be used for CRNA services performed with medical direction by a physician. Documentation must support applicable medical-direction requirements.
Modifier QZ may be used for CRNA anesthesia services performed without medical direction by a physician when appropriate under applicable billing and payer requirements.
Related CPT Codes
CPT 00100 applies to anesthesia for procedures involving the salivary glands, including biopsy. It represents a different type of head procedure from cleft lip repair.
CPT 00103 applies to anesthesia for qualifying reconstructive eyelid procedures. Review the operative procedure and anatomical site when distinguishing it from CPT 00102.
00172
CPT 00172 applies to anesthesia associated with cleft palate repair and should be distinguished from CPT 00102 when coding anesthesia for craniofacial procedures.
FAQ
What is CPT code 00102 used for?
CPT code 00102 is used to report anesthesia services provided during procedures involving plastic repair of a cleft lip.
Can CPT 00102 be used for both unilateral and bilateral cleft lip repair?
CPT 00102 describes the anesthesia service based on plastic repair of the cleft lip rather than separating the anesthesia code by unilateral or bilateral presentation. The diagnosis coding should reflect the patient's documented condition.
Is CPT 00102 used for cleft palate repair?
No. CPT 00102 specifically applies to anesthesia associated with plastic repair of the cleft lip. Select the appropriate anesthesia code based on the actual procedure performed.
How is CPT 00102 reimbursement calculated?
Anesthesia reimbursement generally considers base units, documented anesthesia time, the applicable conversion factor, and payer-specific payment adjustments.
Does CPT 00102 require anesthesia time documentation?
Anesthesia start and stop times should be accurately documented because anesthesia time is commonly incorporated into anesthesia reimbursement calculations.
Which modifiers can be reported with CPT 00102?
The appropriate modifier depends on how the anesthesia service was provided. Examples include AA for anesthesia personally performed by an anesthesiologist and QX or QZ for qualifying CRNA services. Payer requirements should be verified before billing.
Category
CPT
Reimbursement
Hospital & ASC
Base Units + Time Units
Description
Code Type
Code
00102
Plastic repair of cleft lip
Anesthesia
Common Setting
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