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The procedure described by CPT® Code 21175 involves the surgical reconstruction of the bifrontal region, specifically targeting the superior-lateral orbital rims and the lower forehead. This operation is primarily performed to correct various skeletal deformities, which may include conditions such as plagiocephaly, trigonocephaly, and brachycephaly. These conditions are characterized by abnormal head shapes resulting from premature fusion of skull sutures, leading to asymmetrical or misshapen skulls. The reconstruction aims to restore normal anatomical structure and function, enhancing both aesthetic appearance and cranial integrity. During the procedure, the surgeon may utilize bone grafts, which are typically harvested from the patient's own body, such as the hip, rib, or skull. This autologous approach minimizes the risk of rejection and complications associated with foreign materials. The surgery is performed under general anesthesia, ensuring the patient is completely unconscious and pain-free throughout the operation. To access the surgical site, the physician makes incisions in strategic locations, such as the eyelid or scalp, allowing for optimal visibility and manipulation of the underlying bone structures. The bones are then carefully reshaped and repositioned to achieve the desired contour. If bone grafts are indicated, they are meticulously placed to augment the forehead or orbital rim, providing additional support and structure. To secure the bones in their new positions, various fixation devices, including wires, plates, and screws, may be employed. Finally, the incisions are closed, completing the surgical intervention.
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The procedure described by CPT® Code 21175 is indicated for the correction of specific cranial deformities. These include:
The surgical procedure for CPT® Code 21175 involves several critical steps to ensure effective reconstruction of the cranial structures. The following outlines the procedural steps:
Following 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 follow-up appointments to assess healing and the success of the reconstruction. Patients may experience swelling and bruising in the surgical area, which is a normal part of the recovery process. It is essential for patients to adhere to the surgeon's post-operative instructions to ensure proper healing and minimize the risk of complications.
| Short Descr | RECONSTRUCT ORBIT/FOREHEAD | Medium Descr | RCNSTJ BIFRONTAL SUPERIOR-LAT ORB RIMS & LWR FHD | Long Descr | Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), 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) | 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 | 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 |
| 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. | 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. | 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). | LT | Left side (used to identify procedures performed on the left 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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