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The CPT® Code 21436 refers to the open treatment of a craniofacial separation, specifically a LeFort III type fracture, which is characterized as complicated and involves multiple surgical approaches, internal fixation, and the use of bone grafting. A Le Fort III fracture, also known as craniofacial separation or dysjunction, is a significant and complex injury that affects the midface region. This type of fracture initiates at the nasofrontal and frontomaxillary sutures and extends posteriorly through various anatomical structures, including the medial wall of the orbit, the nasolacrimal groove, and the ethmoid bones. The fracture pathway continues along the floor of the orbit at the inferior orbital fissure and traverses through the lateral orbital wall, zygomaticofrontal junction, and zygomatic arch. Additionally, a branch of the fracture may extend through the base of the perpendicular plate of the ethmoid and vomer, as well as the interface of the pterygoid plates to the base of the sphenoid. The treatment of such complicated fractures necessitates multiple surgical approaches to ensure proper alignment and stabilization of the fractured segments. The procedure includes obtaining a bone graft, which is essential for enhancing the stability of the fractured bone fragments. The use of bone grafting is particularly important in cases where the fracture is comminuted or involves critical structures such as cranial nerve foramina, thereby necessitating meticulous surgical intervention to restore anatomical integrity and function.
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The procedure described by CPT® Code 21436 is indicated for the treatment of complicated LeFort III fractures, which may present with the following conditions:
The open treatment of a complicated LeFort III fracture involves several critical procedural steps to ensure effective stabilization and recovery. The first step is to obtain access to the fracture site, which may be achieved through various incisions. A sublabial incision is commonly used to expose the maxilla, while subciliary or transconjunctival incisions may be employed to access the orbital rim. In cases where additional exposure is necessary, columellar-septal transfixion incisions can be made to reveal the piriform aperture and front maxillary region. If further access is required, incisions in the lateral brow glabellar fold or a bicoronal scalp flap may be utilized. Once adequate exposure is achieved, the fracture is carefully reduced, and anatomic alignment is verified through radiographic imaging. Following reduction, stabilization of the fracture is performed using interdental fixation techniques. In this procedure, as described in CPT® Code 21435, the fracture is disimpacted and reduced through multiple approaches, utilizing miniplates, screws, and/or interosseous wiring to secure the fracture fragments. In addition to these stabilization methods, bone grafting is incorporated into the treatment plan. A bone autograft is harvested, typically from the iliac crest, where a skin incision is made, and the muscle is stripped to expose the bone surface. Cortical and/or cancellous bone is then harvested, shaped to fit the fracture site, and may be morcellized and packed into the fracture area. Internal fixation is subsequently applied to stabilize both the fracture fragments and the bone grafts, ensuring a comprehensive approach to managing the complex injury.
Post-procedure care following the open treatment of a complicated LeFort III fracture includes monitoring for complications such as infection, hematoma formation, and proper healing of the bone grafts. Patients are typically advised to follow specific postoperative instructions, which may include dietary modifications, restrictions on physical activity, and the use of pain management strategies. Follow-up appointments are essential to assess the healing process through clinical evaluation and imaging studies. The expected recovery period may vary based on the extent of the injury and the surgical intervention performed, but patients should be prepared for a gradual return to normal activities as healing progresses. Rehabilitation may also be necessary to restore function and mobility in the affected areas.
| Short Descr | OPTX CRNFCL SEP COMP MLT INT | Medium Descr | OPTX CRNFCL SEP LFT III TYP COMP INT FIXJ W/BONE | Long Descr | Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, internal fixation, 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). | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | 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. |
| 1993-01-01 | Added | First appearance in code book in 1993. |
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