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The procedure described by CPT® Code 21172 involves the surgical reconstruction of the superior-lateral orbital rim and the lower forehead, aimed at correcting skeletal deformities in these areas. This complex surgical intervention may include the advancement or alteration of the bone structure, and it can be performed with or without the use of grafts. When grafts are utilized, they are typically autografts, meaning that the bone material is harvested from the patient's own body, commonly from sites such as the hip, rib, or skull. The procedure is conducted under general anesthesia to ensure the patient is completely unconscious and free from pain during the operation. To access the surgical site, the physician makes incisions in strategic locations, which may include the eyelid or scalp. This access allows the surgeon to reshape and reposition the bones to achieve the desired anatomical correction. If bone grafts are deemed necessary, they are carefully placed to augment the structure of the forehead or orbital rim. To ensure stability and maintain the proper shape of the facial bones during the healing process, various fixation devices such as wires, plates, and screws may be employed. Finally, the incisions made during the procedure are meticulously closed to promote optimal healing and minimize scarring.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 21172 is indicated for patients who present with skeletal deformities of the superior-lateral orbital rim and lower forehead. These deformities may arise from congenital conditions, trauma, or other pathological processes that affect the structural integrity and aesthetic appearance of the facial bones. The reconstruction aims to restore both function and form, improving the patient's overall facial symmetry and structural support.
The surgical procedure begins with the patient being placed under general anesthesia to ensure comfort and immobility throughout the operation. The surgeon then makes incisions in predetermined locations, which may include the eyelid or scalp, to gain access to the underlying bone structures. This careful planning is crucial to minimize visible scarring and to provide optimal access to the surgical site.
After the procedure, patients are typically monitored in a recovery area until the effects of anesthesia wear off. Post-operative care may include pain management, instructions for wound care, and guidelines for activity restrictions to ensure proper healing. Patients may experience swelling and bruising in the surgical area, which is a normal part of the recovery process. Follow-up appointments are essential to monitor healing, assess the results of the surgery, and address any complications that may arise. The overall recovery time can vary depending on the extent of the surgery and the individual patient's healing response.
| Short Descr | RECONSTRUCT ORBIT/FOREHEAD | Medium Descr | RCNSTJ SUPERIOR-LATERAL ORBITAL RIM & LOWER FHD | Long Descr | Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without 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) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | 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 |
| 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). | 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. | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | 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 | Medium Descriptor changed. |
| 1991-01-01 | Added | First appearance in code book in 1991. |
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