Procedure Spotlight: Cleft Lip & Palate Repair

By Stefanie Fario
Of all the congenital medical conditions that can occur in children and newborns cleft lip and palate is one that involves years of dental treatment. While tissue release and palate grafting often take one or two surgeries immediately after birth the child is often left with serious dental complications that need to be addressed from early childhood through adolescence.

Early procedures may involve early intervention orthodontics to bring teeth into proper positions and aid in eruption while sometimes extraction is necessary for teeth that will never achieve proper position, even with interventional therapies. The majority of medical insurances have adopted guidelines to cover what would normally be considered dental treatment under major medical policies should cleft palate be the cause of significant functional impairment.

Codes are available for impressions for prosthesis as well as the prosthesis itself. Modifiers can help denote when more than one provider or perhaps a surgical team is involved to ensure proper reimbursement.

For coverage of treatments resulting from cleft lip and palate it is important to note that the following should always be a part of the patient’s record:

1. Initial evaluation by pediatrician or neonatal physician diagnosing the cleft lip and/or palate.
2. Referral from diagnosing physician.
3. Any early surgical records that document corrections to the lip or palate.
4. Either a panoramic xray or a cephalometric.
5. Intraoral photographs of any areas that will be treated.

For orthodontic treatment it is important to notate both the current phase and how many phases are expected. Code correctly for interceptive, transitional, primary and adolescent dentition. Fixed appliance therapy should be billed separately from the orthodontics.

After orthodontic treatment is complete it may be necessary to equip the patient with temporary dentures, crown and bridge or even implants. At this point more photos should be taken to document the changes from the original consultation and the need for further restorative treatment post-ortho.

Dentists will often see these patients for years after they have been discharged from their other specialists’ care. The dentist is in a unique position to rebuild this young person’s smile and get them through difficult but necessary procedures. Be cognizant of other needs your patient may have. Refer them to speech therapy as needed to cope with prosthetics. Be willing to try different restorative treatments to give them a desired result. Remember to check for preauthorization needs before doing procedures so that your patient is able to receive the maximum insurance benefit. Be the amazing dentist who gives a child back their smile!
Dental Billing Tips and News for Pros; Edition #130