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The CPT® Code 21422 refers to the open treatment of a palatal or maxillary fracture classified as LeFort I type. This procedure is performed to address fractures that occur in the upper jaw, specifically in the maxilla, which is the bone that forms the upper jaw and supports the teeth. The term "LeFort I" describes a specific type of fracture that involves a horizontal fracture line above the teeth, which can lead to significant displacement of the maxillary bone. During the procedure, the physician makes incisions in the buccal vestibule, which is the area of the oral cavity adjacent to the gums. This approach allows for direct access to the fractured bone. Once the fracture is exposed, the physician carefully repositions the bone segments to their correct anatomical alignment. To ensure stability and proper healing, the repositioned bone segments are secured using various fixation devices such as screws, plates, or pins. After the stabilization is complete, the incisions made during the procedure are closed. In some cases, additional methods such as intermaxillary or interdental fixation may be employed to provide further support and stabilization to the fracture during the healing process.
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The open treatment of palatal or maxillary fractures (LeFort I type) is indicated for patients who present with specific conditions related to the upper jaw. These indications include:
The open treatment of a palatal or maxillary fracture (LeFort I type) involves several critical procedural steps:
After the open treatment of a palatal or maxillary fracture (LeFort I type), patients can expect specific post-procedure care and considerations. Initially, patients may experience swelling, bruising, and discomfort in the surgical area, which can be managed with prescribed pain medications. It is essential for patients to follow the physician's instructions regarding diet, as a soft or liquid diet may be recommended to avoid putting stress on the healing maxilla. Follow-up appointments will be necessary to monitor the healing process and to remove any sutures if non-dissolvable materials were used. Patients may also need to adhere to any prescribed intermaxillary or interdental fixation protocols to ensure proper stabilization during recovery. Overall, the expected recovery time can vary based on the individual’s health and the extent of the fracture, but adherence to post-operative care is crucial for optimal healing and restoration of function.
| Short Descr | OPTX PALATAL/MAX FRACTURE | Medium Descr | OPEN TREATMENT PALATAL/MAXILLARY FRACTURE | Long Descr | Open treatment of palatal or maxillary fracture (LeFort I type); | 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) | 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 |
| 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. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, 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 | GJ | "opt out" physician or practitioner emergency or urgent service | 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) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2025-01-01 | Changed | Short Description changed. |
| 2010-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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