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The procedure described by CPT® Code 21145 involves the surgical reconstruction of the midface using a technique known as LeFort I osteotomy. This procedure is typically indicated for patients who have facial bone deformities or for those seeking cosmetic enhancements. The LeFort I osteotomy specifically targets the lower maxillary region, which is anatomically defined as the area below the infraorbital nerve and medial to the zygomatic-maxillary suture. During the procedure, the physician may need to extract premolars and last molars to facilitate access and ensure proper alignment of the maxilla. The surgical approach includes tunneling the palatal mucosa to minimize tissue damage during the osteotomy. An incision is made in the buccal sulcus, extending from the first molar on one side to the first molar on the opposite side, allowing for exposure of the lateral aspect of the nasal cavity and elevation of the nasal mucosa. Precise measurements are taken prior to surgery to guide the planned bone cuts in the maxilla. The procedure involves careful manipulation of the maxilla, including cutting, fracturing, and mobilizing the bone, followed by stabilization and repositioning with the use of bone grafts. The inclusion of bone grafts, which may be harvested from the iliac crest or other sites, is essential for achieving the desired structural support and aesthetic outcome. This comprehensive approach ensures that the midface is reconstructed effectively, addressing both functional and cosmetic needs.
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The LeFort I osteotomy procedure, as described by CPT® Code 21145, is indicated for the following conditions:
The procedure begins with the extraction of premolars and last molars as necessary to facilitate access to the maxilla. The palatal mucosa is carefully tunneled to prevent tearing during the maxillary osteotomy. An incision is made in the buccal sulcus, extending from the first molar on one side to the first molar on the opposite side, which allows for exposure of the lateral aspect of the nasal cavity. The nasal mucosa is then elevated to provide a clear view of the surgical field. Using preoperative measurements, the physician marks the planned bone cuts in the maxilla. A bur is used to cut the lateral wall of the maxilla on one side, followed by the placement of a thin osteotome in the cut. Gentle pressure is applied to fracture the medial and posterior wall of the maxilla. The pterygoid plate is then separated from the maxilla using a pterygoid osteotome, and the pterygoid hamulus is located and carefully separated from the pterygoid plate. This process is repeated on the opposite side of the maxilla to ensure symmetry.
Next, the nasal septum cartilage and vomer are separated from the maxilla using a septal gouge or osteotome. After fracturing the anterior nasal spine, the gouge or osteotome is angled towards the floor of the nose to facilitate further separation. The maxilla is then downfractured using thumb pressure and mobilized with the pterygoid osteotome. Once the maxilla is completely detached and mobile, an anterior osteotomy is performed at the premolar region bilaterally. The nasal septal cartilage, posterior wall, and palatal bone are trimmed to achieve the desired contour. The maxilla is repositioned and stabilized with wires, and measurements are checked to confirm that the desired repositioning has been achieved. The lip position and occlusion are also assessed to ensure proper alignment.
Bone grafts are harvested from the iliac crest or another suitable site. If the iliac crest is chosen, a skin incision is made over the crest, and the muscle is stripped to expose the bone surface. Cortical and/or cancellous bone is harvested, configured to the desired size and shape, and/or morcellized and placed in the defect. An intermaxillary fixation device is then applied to maintain the position of the maxilla during the healing process. Finally, the buccal incision is closed to complete the procedure.
Post-procedure care involves monitoring the patient for any complications and ensuring proper healing of the surgical site. Patients may experience swelling and discomfort, which can be managed with appropriate pain relief measures. Follow-up appointments are essential to assess the healing process, check the stability of the bone grafts, and ensure that the maxilla remains in the desired position. Patients are typically advised on dietary restrictions and oral hygiene practices to promote healing and prevent infection. The overall recovery time may vary depending on individual circumstances, but close adherence to post-operative instructions is crucial for optimal outcomes.
| Short Descr | LEFORT I-1 PIECE W/ GRAFT | Medium Descr | RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS | Long Descr | Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P3D - Major procedure, orthopedic - other | MUE | 1 | CCS Clinical Classification | 161 - Other OR therapeutic procedures on bone |
| 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2013-01-01 | Changed | Short Descriptor changed. |
| 2011-01-01 | Changed | Short description changed. |
| 1991-01-01 | Added | First appearance in code book in 1991. |
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