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The procedure described by CPT® Code 21346 involves the open treatment of a nasomaxillary complex fracture, specifically classified as a LeFort II type fracture. This type of fracture, often referred to as a pyramidal fracture, typically occurs in the midface region and can result from significant trauma. The physician performs the repair in an open surgical environment, which allows for direct visualization and manipulation of the fractured bones. Access to the fracture site is achieved through an incision made in the cheek area, providing the surgeon with the necessary access to realign the fractured components accurately. During the procedure, the physician carefully manipulates the fractured area to restore its normal anatomical position. To ensure stability and proper healing of the fracture, various fixation methods are employed, including the use of screws, wires, and/or plates. Once the fracture is stabilized, the incisions made during the procedure are meticulously closed. In some cases, intermaxillary fixation may be required to maintain the alignment of the jaw during the healing process. This comprehensive approach aims to restore function and aesthetics to the midface region following a significant injury.
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The procedure is indicated for the treatment of specific types of fractures in the midface region, particularly those that fall under the category of nasomaxillary complex fractures. The following conditions may warrant the use of this surgical intervention:
The open treatment of a nasomaxillary complex fracture (LeFort II type) involves several critical procedural steps to ensure effective repair and stabilization of the fracture site. Each step is essential for achieving optimal outcomes.
After the completion of the procedure, patients typically require careful monitoring and follow-up care to ensure proper recovery. Post-procedure care may include pain management, instructions for oral hygiene, and dietary modifications to accommodate any restrictions related to jaw movement. Patients may also need to attend follow-up appointments to assess the healing process and the stability of the fracture repair. In cases where intermaxillary fixation was utilized, the duration of this fixation will be determined by the surgeon based on the individual patient's healing progress. Overall, the goal of post-procedure care is to facilitate a smooth recovery and restore normal function to the midface region.
| Short Descr | OPN TX NASOMAX FX W/FIXJ | Medium Descr | OPTX NASOMAX CPLX FX LEFT II TYPE W/WIRG & FXJ | Long Descr | Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local 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) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies 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 | 144 - Treatment, facial fracture or dislocation |
| 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. | 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.) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | 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 | Description Changed |
| Pre-1990 | Added | Code added. |
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