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The procedure described by CPT® Code 21465 refers to the open treatment of a mandibular condylar fracture, which is a type of fracture occurring in the condyle of the mandible, the bone that forms the lower jaw. This procedure is typically performed by an oral and maxillofacial surgeon or a physician specializing in head and neck surgery. The approach involves making an incision near or through the ear, which allows the surgeon to gain direct access to the fractured area. In some cases, an intraoral incision may be utilized to reach the fracture site more effectively. Once access is achieved, the surgeon carefully dissects the surrounding soft tissue to expose the temporomandibular joint (TMJ) and the fractured condyle. The primary goal of the procedure is to reduce the fracture, meaning the surgeon will reposition the fractured bone fragments back into their correct anatomical alignment. This is crucial for restoring function and preventing complications such as malocclusion or chronic pain. After the fracture is reduced, the condyle is secured in place using various fixation methods, which may include screws, wires, or plates. In certain situations, the fracture may be stable enough that internal fixation is not required. Following the completion of the procedure, all incisions are meticulously closed to promote healing. Additionally, the surgeon may opt to use intermaxillary fixation, a technique that temporarily immobilizes the jaw, if deemed necessary for optimal recovery.
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The open treatment of a mandibular condylar fracture, as described by CPT® Code 21465, is indicated for specific conditions and symptoms that necessitate surgical intervention. These indications include:
The open treatment of a mandibular condylar fracture involves several critical procedural steps to ensure successful outcomes. These steps include:
After the open treatment of a mandibular condylar fracture, patients can expect specific post-procedure care and considerations. It is essential for patients to follow the surgeon's instructions regarding pain management, dietary restrictions, and activity limitations to ensure proper healing. Patients may experience swelling and discomfort in the initial days following the surgery, which can be managed with prescribed medications. Follow-up appointments will be necessary to monitor the healing process and assess the stability of the fracture. The surgeon will provide guidance on when normal activities can be resumed and may recommend physical therapy to restore full function of the jaw. Additionally, patients should be aware of signs of complications, such as increased pain, fever, or unusual swelling, and report these to their healthcare provider promptly.
| Short Descr | OPTX MNDBLR CNDYLR FX | Medium Descr | OPEN TREATMENT MANDIBULAR CONDYLAR FRACTURE | Long Descr | Open treatment of mandibular condylar fracture | 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) | 1 - 150% payment adjustment for bilateral procedures applies. | 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 | ASC Payment Indicator | Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate. | 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 |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 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). | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure 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) | 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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