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The procedure described by CPT® Code 21196 involves the surgical reconstruction of the mandibular rami and/or body through a technique known as a sagittal split. This procedure is typically performed to correct various dental and skeletal deformities, improve occlusion, or address trauma-related injuries to the mandible. During the surgery, the physician makes an incision over the mandibular ramus, which is the vertical part of the mandible. The use of specialized instruments such as saws, drills, and osteotomes allows the surgeon to carefully separate the mandible at the predetermined site. Once the mandible is split, it can be repositioned forward to achieve the desired alignment and functional outcome. The fixation of the mandible in its new position is crucial for the success of the procedure; in this case, internal rigid fixation devices are utilized to maintain stability and support during the healing process. After the reconstruction is complete, the incisions are meticulously closed to promote optimal recovery and minimize scarring.
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The procedure described by CPT® Code 21196 is indicated for various conditions related to the mandible, including:
The procedure for CPT® Code 21196 involves several critical steps to ensure successful reconstruction of the mandibular rami and/or body:
Post-procedure care following the reconstruction of the mandibular rami and/or body with internal rigid fixation involves monitoring the surgical site for signs of infection and ensuring proper healing. Patients may be advised to follow a soft diet to minimize stress on the jaw during the initial recovery phase. Pain management strategies will be implemented to address any discomfort. Follow-up appointments are essential to assess the healing process and the stability of the fixation devices. The healthcare team will provide specific instructions regarding activity restrictions and oral hygiene practices to support recovery.
| Short Descr | RECONST LWR JAW W/FIXATION | Medium Descr | RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FI | Long Descr | Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation | 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) | 2 - 150% payment adjustment 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 |
| 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. | 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. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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) | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner |
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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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