CPT 00102: Anesthesia for Plastic Repair of Cleft Lip
CPT code 00102 designates anesthesia services for plastic repair of a cleft lip, a common pediatric and reconstructive procedure requiring perioperative anesthesia management. This code identifies the anesthesia component separate from the surgical procedure and is used in billing to capture professional anesthesia time and complexity for cleft lip repairs. Nationally, accurate use of this code ensures appropriate attribution of anesthesia services for resource tracking and payment.
Key payers included in the analysis are Aetna, Blue Cross Blue Shield, Cigna Health, United Healthcare, and Medicare. Readers will find an overview of coverage considerations across major payers, commonly associated modifiers, and clinical context relevant to anesthesia for cleft lip repair. The publication summarizes where this code fits within anesthesia billing, highlights related CPT anesthesia codes, and provides guidance on documentation elements typically associated with services of this nature.
The content is intended to inform billing staff, anesthesiology providers, coding professionals, and policy analysts about the clinical and billing context of CPT code 00102, its role in surgical care episodes for cleft lip repair, and the expectations for payer interactions and coding accuracy at a national level.
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Billing Code Overview
CPT code 00102 describes anesthesia services provided for a patient undergoing plastic repair of a cleft lip. The service is an anesthesia procedure delivered in support of a surgical repair of congenital cleft lip deformity.
Service type: Anesthesia for reconstructive/repair surgery
Typical site of service: Operating room or ambulatory surgical center, where surgical correction of a cleft lip is performed.
Clinical & Coding Specifications
Clinical Context
A 6-month-old infant with a unilateral congenital cleft lip is scheduled for primary cleft lip repair in the ambulatory pediatric surgical suite. The child presents preoperatively to the anesthesia clinic for evaluation, including history of feeding difficulties and intermittent upper respiratory symptoms. The anesthesia team (pediatric anesthesiologist or Certified Registered Nurse Anesthetist under supervision) performs a pre-anesthetic assessment, documents American Society of Anesthesiologists (ASA) physical status P2, and obtains informed consent for general anesthesia with endotracheal intubation.
On the day of surgery, standard monitors are applied. An induction with inhaled sevoflurane or intravenous agents is performed, followed by tracheal intubation with a cuffed or uncuffed endotracheal tube appropriate for age, with attention to airway anomalies. The provider administers anesthetic maintenance, analgesia (intravenous opioids and local infiltration by the surgeon), and intraoperative antiemetic prophylaxis as indicated. The anesthesia record documents induction time, airway management, vital signs, estimated blood loss, and emergence. Postoperative care includes transfer to post-anesthesia care unit (PACU) with monitoring for airway patency, bleeding, and pain control. Discharge occurs when PACU recovery criteria are met or transfer to an inpatient pediatric unit if complications arise.
Billing for the anesthetic service is reported with 00102 to reflect anesthesia for plastic repair of cleft lip; appropriate modifiers are appended based on circumstances such as provider type, unusual procedural difficulty, or concurrent care.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
AA | Anesthesia services performed personally by anesthesiologist | Use when an anesthesiologist personally performs the service. |
AD | Medical supervision by a physician; more than four concurrent anesthesia procedures | Use when the physician supervises multiple concurrent CRNAs and billing requires the supervision modifier. |
QK | Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals | Use when medical direction criteria are met for multiple procedures. |
QS | Monitored anesthesia care (MAC) service | Use when the anesthesia service is MAC rather than general anesthesia. |
QX | CRNA service: administered under physician supervision | Use when a Certified Registered Nurse Anesthetist performs the service supervised by a physician. |
QY | Anesthesiologist medically directs one CRNA | Use when an anesthesiologist medically directs a single CRNA for the procedure. |
62 | Two surgeons | Use when two surgeons perform distinct portions of the operation requiring separate surgeon billing; appended to anesthesia only if relevant to payer rules. |
23 | Unusual anesthesia | Use when administration of anesthesia is significantly more difficult or required due to unusual circumstances. |
50 | Bilateral procedure | Use when a bilateral cleft repair procedure is performed (if applicable clinically). |
78 | Unplanned return to the operating room for a related procedure during the postoperative period | Use when the patient returns to OR for a complication related to the index repair and anesthesia is provided. |
53 | Discontinued procedure | Use when the anesthetic is initiated but the procedure is discontinued prior to completion. |
52 | Reduced services | Use when the anesthetic service is partially reduced due to clinical reasons. |
22 | Increased procedural services | Use to report unusually high work or complexity for the anesthetic service. |
AA | (listed above) | Duplicate listing of AA is not intended; included only once in billing. |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207L00000X | Anesthesiology | Physician specialty providing perioperative anesthesia services for pediatric and adult patients. |
207LA0401X | Pain Medicine (Anesthesiology) | Anesthesiologists with additional pain management training; may be involved in perioperative analgesia planning. |
367500000X | Certified Registered Nurse Anesthetist | CRNAs who commonly administer anesthesia for cleft lip repair under appropriate state and facility supervision rules. |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
K11.9 | Disease of salivary gland, unspecified | May be listed when salivary gland pathology is present or considered concurrently; relevant to facial/oral surgeries affecting perioperative planning. |
K11.5 | Sialolithiasis | Presence of salivary gland stones could necessitate intraoral or facial procedures under anesthesia and may co-occur or complicate airway/operative planning. |
K11.8 | Other specified diseases of salivary glands | Captures specified salivary gland conditions that could be evaluated or treated during related otolaryngology or plastic procedures requiring anesthesia. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
00100 | ANESTHESIA PX ON SALIVARY GLANDS WITH BIOPSY | Related anatomically and by anesthesia service group; used when procedures on the salivary glands with biopsy are performed requiring anesthesia services similar in complexity. |
00103 | ANESTHESIA RECONSTRUCTIVE PROCEDURES OF EYELID | Related as another facial reconstructive anesthesia code; useful for cross-referencing anesthesia valuation for adjacent facial procedures. |
00104 | ANESTHESIA ELECTROCONVULSIVE THERAPY | Listed as a related anesthesia code in the series; distinct clinical procedures but within the anesthesia coding family. |