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T494
T494 – T494
OHIP Other Code · Schedule of Benefits
When to Use
- Use T494 for the surgical repair of a complete or incomplete cleft palate, typically performed by a plastic surgeon or otolaryngologist.
- Apply this code when the procedure involves the primary closure of a cleft palate, distinct from secondary revisions or pharyngoplasty procedures.
- Select T494 when the clinical documentation confirms a formal palatoplasty procedure rather than a minor soft tissue revision coded under different minor surgical fee schedules.
Common Pitfalls
- Billing T494 in conjunction with other surgical procedures on the same site without appropriate modifier usage can lead to automatic claim rejection for unbundling.
- Failure to include the required diagnostic code for cleft palate (ICD-9 749.0) will result in a claim rejection for diagnostic mismatch.
- Attempting to bill an additional office visit fee on the same day as T494 is considered double-dipping, as the global surgical fee includes the immediate pre-operative and post-operative assessment.
Billing Tips
- Ensure that the surgical report explicitly details the complexity of the closure to support the high-value fee if audited against standard minor repair codes.
- If a secondary procedure is performed during the same operative session, ensure you append the appropriate percentage-based reduction for the secondary procedure to avoid claim denial.
Provider Fee$619.52
Specialist Fee$619.52
Effective: April 1, 2025
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