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The CPT® Code 21421 refers to the closed treatment of a palatal or maxillary fracture classified as LeFort I type. This procedure is characterized by the absence of incisions, meaning that it is performed without any surgical cuts to the tissue. Instead, the physician utilizes interdental wire fixation, which involves securing the dental arches within the patient's mouth to stabilize the fracture. This method is crucial for maintaining the proper alignment of the maxilla during the healing process. Additionally, in some cases, the physician may opt to use dentures or splints as alternative means of fixation to provide the necessary support for the fractured area. The goal of this procedure is to ensure that the maxillary structure heals correctly, thereby restoring function and aesthetics to the patient's oral cavity.
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The closed treatment of palatal or maxillary fractures (LeFort I type) is indicated for patients who have sustained specific types of facial injuries. These injuries typically involve fractures of the maxilla, which may occur due to trauma from accidents, falls, or sports-related incidents. The procedure is performed when the fracture is deemed stable enough to be treated without surgical incisions, allowing for a less invasive approach to stabilization and healing.
The closed treatment procedure for a LeFort I type fracture involves several key steps to ensure proper stabilization of the maxillary structure. First, the physician will assess the fracture through clinical examination and imaging studies to confirm the diagnosis and determine the appropriate treatment plan.
After the closed treatment procedure, patients are typically monitored for any signs of complications, such as infection or misalignment. Post-procedure care may include instructions on oral hygiene to prevent infection and recommendations for dietary modifications to avoid placing undue stress on the healing maxilla. Follow-up appointments are essential to assess the healing process and make any necessary adjustments to the fixation devices. Patients can expect a gradual return to normal function as the fracture heals, which may take several weeks depending on the severity of the injury.
| Short Descr | CLTX PALATAL/MAX FX WIRE FIX | Medium Descr | CLOSED TX PALATAL/MAXILLARY FX W/FIXATION/SPLINT | Long Descr | Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint | 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) | 0 - Payment restriction for assistants at surgery applies 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 | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | 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). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | FS | Split (or shared) evaluation and management visit | 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) |
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| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
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