Summary & Overview
CPT 42260: Nasolabial Fistula Repair, Surgical Closure
CPT code 42260 covers the surgical repair of a nasolabial fistula, an abnormal tract between the nasal cavity and the space under the upper lip. This procedure addresses persistent nasal drainage, recurrent infection, and functional or cosmetic deficits arising from the fistula. Nationally, the code matters because it captures a focused, reconstructive surgical service that may affect utilization in otolaryngology, facial plastic, and oral/maxillofacial practice settings.
Key payers in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical indications and typical sites of service, plus payer coverage context and commonly reported modifiers. The publication outlines benchmarks for how this procedure is classified and billed, summarizes relevant policy considerations that influence coverage and prior authorization, and provides clinical context describing when surgical repair is indicated.
The content is intended for national audiences including coding professionals, practice managers, and specialty clinicians. It clarifies the clinical intent of CPT code 42260, highlights payer relevance, and identifies the practical billing and administrative topics readers should review when managing claims for nasolabial fistula repair.
Billing Code Overview
CPT code 42260 describes the surgical repair of a nasolabial fistula, an abnormal connection between the nasal cavity and the space beneath the upper lip. The procedure restores normal separation between the nasal passages and oral/vermilion spaces to address issues such as chronic nasal drainage, recurrent infection, or functional and cosmetic concerns.
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Service type: Surgical repair of nasolabial fistula
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Typical site of service: Ambulatory surgical center or hospital operating room, performed by specialists in otolaryngology (ENT), facial plastic surgery, or oral and maxillofacial surgery
Clinical & Coding Specifications
Clinical Context
A typical patient is an adult or adolescent presenting with a persistent nasolabial fistula — an abnormal epithelialized tract between the nasal cavity and the oral vestibule beneath the upper lip — often resulting from prior facial trauma, dental extraction complications, chronic infection, or previous cleft lip/palate surgery. The patient reports chronic nasal regurgitation of fluids, recurrent sinusitis, nasal crusting, or an oronasal communication visible on inspection. Examination includes nasal endoscopy and intraoral inspection, possible CT imaging to assess bony defects and sinus involvement, and dental evaluation if odontogenic infection is suspected. Preoperative planning includes assessing fistula size, location, surrounding tissue quality, and need for local flap or layered closure. The procedure 42260 is performed in an outpatient ambulatory surgical center or hospital minor procedure room under local anesthesia with sedation or general anesthesia, depending on complexity and patient factors. Typical workflow: preoperative consent and antisepsis, surgical excision or freshening of the fistulous tract, layered closure with mucosal and subcutaneous flaps and possible cartilage or soft-tissue grafting, hemostasis, and postoperative instructions for oral/nasal hygiene and activity restriction. Postoperative follow-up at 1 week for wound check and at 4–8 weeks for functional assessment and confirmation of fistula closure.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 |