How To Use CPT Code 21070

CPT 21070 describes the surgical procedure known as coronoidectomy, which involves the removal of the coronoid process of the mandible. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 21070?

CPT 21070 is used to describe the surgical procedure called coronoidectomy. This procedure involves the removal of the coronoid process of the mandible, which is the bony projection at the anterior end of the lower jaw bone. Coronoidectomy is typically performed to treat conditions such as injury, ankylosis, arthritis, or other disorders affecting the mandible.

2. Official Description

The official description of CPT code 21070 is: ‘Coronoidectomy (separate procedure).’ It is important to note that for bilateral procedures, modifier 50 should be appended to the code.

3. Procedure

During a coronoidectomy, the patient is appropriately prepped and anesthetized. The provider begins by making a curvilinear incision in front of the tragus line, which is an anatomical landmark in front of the ear. Fascia and underlying muscles are dissected and retracted to expose the mandible. The provider then identifies the coronoid process of the mandible and uses a bone drill or osteotome to remove the diseased or restricted part of the coronoid process. Care is taken to preserve the condyle and meniscus. The dissected coronoid is removed using surgical forceps. The provider assesses the jaw for satisfactory movement and may apply a bone graft or synthetic graft material to fill the defect left by the coronoidectomy. The incision is closed using sutures in a complex layered fashion.

4. Qualifying circumstances

CPT 21070 is performed when there is a need to remove the coronoid process of the mandible due to conditions such as injury, ankylosis, arthritis, or other disorders affecting the mandible. The procedure is typically performed by a qualified healthcare professional who has the necessary training and expertise in performing surgical procedures on the head and neck.

5. When to use CPT code 21070

CPT code 21070 should be used when a provider performs a coronoidectomy as a separate procedure. It is important to note that for bilateral procedures, modifier 50 should be appended to the code.

6. Documentation requirements

To support a claim for CPT 21070, the healthcare professional must document the following information:

• Patient’s diagnosis and the need for coronoidectomy
• Details of the surgical procedure performed, including the specific steps taken
• Any additional procedures or techniques used during the surgery
• Any complications or unexpected findings encountered during the procedure
• Any bone grafting or synthetic graft material used
• Details of the closure technique used
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 21070, it is important to ensure that the procedure was performed as a separate procedure. If the procedure was performed bilaterally, modifier 50 should be appended to the code. It is also important to follow any specific billing guidelines provided by the payer or insurance company.

8. Historical information

CPT 21070 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 21070

There are several similar codes to CPT 21070 that describe other excision procedures on the head. Some examples include:

• CPT 21011: Excision of tumor or cyst of maxilla or zygoma
• CPT 21012: Excision of tumor or cyst of mandible
• CPT 21025: Excision of tumor or cyst of nasal bone
• CPT 21040: Excision of tumor or cyst of palate or uvula
• CPT 21045: Excision of tumor or cyst of floor of mouth

9. Examples

1. A patient undergoes a coronoidectomy to treat ankylosis of the mandible.
2. A provider performs a coronoidectomy to remove a tumor from the coronoid process of the mandible.
3. A patient with arthritis in the mandible undergoes a coronoidectomy to alleviate pain and improve jaw movement.
4. A provider performs a coronoidectomy as part of a reconstructive surgery following a traumatic injury to the mandible.
5. A patient with a history of recurrent infections in the mandible undergoes a coronoidectomy to prevent further complications.
6. A provider performs a coronoidectomy to address a congenital abnormality in the mandible.
7. A patient with ankylosis and limited jaw movement undergoes a coronoidectomy to improve their ability to eat and speak.
8. A provider performs a coronoidectomy to remove a cyst from the coronoid process of the mandible.
9. A patient with severe arthritis in the mandible undergoes a coronoidectomy to improve their quality of life.
10. A provider performs a coronoidectomy as part of a larger surgical procedure to address multiple issues in the mandible.