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The CPT® Code 21445 refers to the open treatment of fractures occurring in the mandibular or maxillary alveolar ridge, classified as a separate procedure. This surgical intervention is typically performed to address fractures that affect the bony structures of the jaw, which are crucial for dental support and overall oral function. The procedure involves the physician making incisions in the buccal vestibule of the maxilla, which is the area inside the mouth adjacent to the gums. Through these incisions, the physician can access the fractured site directly. The manipulation of the fractured bone is essential to realign the fragments properly, ensuring that they are positioned correctly for optimal healing. To stabilize the fracture, various fixation devices such as plates, screws, and wires are employed. In some cases, the use of arch bars and dental wire may be necessary to provide additional support. Alternative methods for stabilization can include intermaxillary fixation, which involves securing the upper and lower jaws together, or the creation of a custom acrylic splint to maintain the alignment of the jaw during the healing process. After the necessary stabilization techniques are applied, all incisions made during the procedure are carefully closed to promote healing and minimize complications.
© Copyright 2025 Coding Ahead. All rights reserved.
The open treatment of mandibular or maxillary alveolar ridge fractures is indicated in the following scenarios:
The procedure for the open treatment of mandibular or maxillary alveolar ridge fractures involves several critical steps:
Post-procedure care following the open treatment of mandibular or maxillary alveolar ridge fractures typically involves monitoring for complications and ensuring proper healing. Patients may be advised to follow a soft diet to minimize stress on the jaw during the initial recovery phase. Pain management strategies may be implemented to address discomfort following surgery. Additionally, follow-up appointments are essential to assess the healing process and to remove any fixation devices if applicable. Patients should be educated on signs of infection or complications, such as increased swelling, fever, or unusual pain, and instructed to seek medical attention if these occur. Overall, adherence to post-operative care instructions is crucial for optimal recovery and restoration of function.
| Short Descr | OPTX MNDBLR/MAX ALV RIDGE FX | Medium Descr | OPTX MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX SPX | Long Descr | Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) | 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) | 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 | 2 | 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. | 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.) | 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) |
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| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
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