© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 21348 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 affects the midface and involves the maxilla and nasal bones. The open treatment approach allows the physician to directly access the fracture site through multiple surgical incisions, facilitating a thorough examination and repair of the damaged structures. During the procedure, the physician obtains a bone graft, which is a piece of bone taken from another part of the patient's body, such as the hip, rib, or skull. This graft is essential for filling in the defect areas created by the fracture, promoting healing and stability. The fractured bones are realigned through careful manipulation, and the physician employs various fixation methods, including screws, wires, and plates, to stabilize the fracture site effectively. After the repair, all incisions are meticulously closed to promote optimal healing. In some cases, intermaxillary fixation may be required to maintain the proper alignment of the jaw during the recovery process.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure is indicated for patients presenting with a nasomaxillary complex fracture classified as LeFort II type. This type of fracture may occur due to significant facial trauma, which can result from various incidents such as vehicular accidents, falls, or physical altercations. Symptoms may include facial deformity, pain, swelling, and difficulty with oral function or breathing due to the displacement of the maxilla and nasal structures.
The open treatment of a nasomaxillary complex fracture (LeFort II type) involves several critical procedural steps to ensure proper alignment and stabilization of the fractured bones.
After the procedure, patients are typically monitored for any immediate complications. Post-operative care may include pain management, instructions for oral hygiene, and dietary modifications to accommodate any swelling or discomfort. Patients may also be advised on the importance of follow-up appointments to assess healing and ensure that the fracture remains stable. Recovery time can vary based on the extent of the injury and the individual patient's healing process. It is essential for patients to adhere to their surgeon's post-operative instructions to promote optimal recovery and minimize the risk of complications.
| Short Descr | OPN TX NASOMAX FX W/GRAFT | Medium Descr | OPTX NASOMAX CPLX FX LEFT II TYPE W/BONE GRAFT | Long Descr | Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining graft) | 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) | 2 - Co-surgeons permitted and no documentation required if the two- specialty requirement is met. | 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 | 144 - Treatment, facial fracture or dislocation |
| 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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. | GC | This service has been performed in part by a resident under the direction of a teaching physician |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2013-01-01 | Changed | Short Descriptor changed. |
| 1993-01-01 | Added | First appearance in code book in 1993. |
Get instant expert-level medical coding assistance.