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The procedure described by CPT® Code 21160 involves a complex surgical intervention known as midface reconstruction using a LeFort III osteotomy, which is a type of facial surgery that addresses significant structural deformities in the midface region. This procedure is particularly intricate as it encompasses both extraoral and intracranial components, indicating that the surgery extends beyond the facial structures into the cranial area. The term "forehead advancement" refers to the repositioning of the forehead and upper facial structures, often performed in conjunction with a mono bloc technique, which involves moving the midface and forehead as a single unit. The procedure necessitates the use of bone grafts, which are harvested from the patient's own body—typically from the hip, rib, or skull—to provide the necessary material for reconstructing the facial skeleton. The LeFort I procedure, which is also included in this code, involves the repositioning of the maxilla (upper jaw) to correct alignment and improve function and aesthetics. The surgical approach requires general anesthesia, and the surgeon makes various incisions, which may include transoral (through the mouth), lower eyelid, and scalp incisions, to access the facial bones. During the operation, the midfacial and frontal bones are carefully manipulated and detached from the cranial base, allowing for precise repositioning. The use of specialized instruments such as osteotomes, saws, and burs is essential for reshaping the bone structures as needed. After the midface and maxilla are repositioned, the harvested bone grafts are inserted into designated areas to support the new structure. Fixation of the bones is achieved using plates, screws, and wires to ensure stability during the healing process. An antibiotic solution is applied to reduce the risk of infection, and the incisions are meticulously closed. In some cases, intermaxillary fixation may be required to maintain the position of the jaw during recovery.
© Copyright 2025 Coding Ahead. All rights reserved.
The LeFort III reconstruction procedure, as described by CPT® Code 21160, is indicated for patients presenting with significant midfacial deformities that may arise from congenital conditions, traumatic injuries, or other pathological processes. The following conditions may warrant this surgical intervention:
The surgical procedure for CPT® Code 21160 involves several critical steps to ensure successful midface reconstruction:
After the completion of the LeFort III reconstruction procedure, patients are typically monitored in a recovery area until the effects of anesthesia wear off. Post-operative care may include pain management, monitoring for signs of infection, and ensuring proper healing of the incisions. Patients may be advised to follow a soft diet and avoid strenuous activities for a specified period to facilitate recovery. Follow-up appointments are essential to assess the healing process and the positioning of the facial structures. Any necessary adjustments or interventions can be addressed during these visits to ensure optimal outcomes.
| Short Descr | LEFORT III W/FHD W/ LEFORT I | Medium Descr | RCNSTJ MIDFACE LEFORT III W/FHD W/LEFORT I | Long Descr | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I | 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. |
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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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