How To Use CPT Code 21141

CPT code 21141 describes the reconstruction of the midface, specifically a LeFort I single piece procedure, which involves segment movement in any direction. 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 21141?

CPT code 21141 is used to describe a specific type of facial reconstruction procedure known as a LeFort I single piece surgery. This procedure involves the movement of segments of the midface in any direction to correct congenital or acquired deformities, such as long face syndrome. Long face syndrome is characterized by an elongation of the lower face, often caused by childhood mouth breathing. The purpose of the LeFort I single piece procedure is to reposition the maxilla, or upper jaw bone, and associated bones forward, thereby correcting the deformity.

2. Official Description

The official description of CPT code 21141 is: ‘Reconstruction midface, LeFort I single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft.’

3. Procedure

The LeFort I single piece procedure involves several steps to reconstruct the midface and correct the deformity:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision in the maxillary area.
3. The maxilla is separated from the skull base.
4. The provider repositions the maxilla into the predetermined location.
5. A predetermined bone segment is repositioned into place.
6. If necessary, the provider molds and shapes a dental appliance to the defect intraoperatively.
7. The provider packs the cavity with surgical gauze or a similar material.
8. A palatal obturator is positioned and secured in place with a single screw through the residual hard palate.
9. The provider checks for bleeding, removes any instruments, and closes the incision with layered sutures.

4. Qualifying circumstances

CPT code 21141 is typically performed to correct congenital or acquired deformities of the midface, such as long face syndrome. The procedure involves the movement of segments of the midface in any direction without the use of a bone graft. It is important to note that preauthorization is often recommended for this procedure to ensure that it is performed for medically necessary reasons rather than cosmetic purposes.

5. When to use CPT code 21141

CPT code 21141 should be used when a provider performs a LeFort I single piece procedure to reconstruct the midface and correct congenital or acquired deformities, such as long face syndrome. This code specifically applies to cases where segment movement in any direction is involved, without the use of a bone graft.

6. Documentation requirements

To support a claim for CPT code 21141, the provider must document the following information:

• Patient’s diagnosis and the need for midface reconstruction
• Details of the LeFort I single piece procedure performed
• Date of the procedure
• Start and end time of the procedure
• Specific segment movement and direction
• Use or non-use of a bone graft
• Any additional procedures or techniques used during the surgery
• Post-operative care instructions, if applicable
• Signature of the performing provider

7. Billing guidelines

When billing for CPT code 21141, it is important to ensure that the procedure performed aligns with the specific requirements of the code. The LeFort I single piece procedure should involve segment movement in any direction without the use of a bone graft. It is also recommended to obtain preauthorization for this procedure to indicate medical necessity. Additionally, it is important to follow any specific billing guidelines provided by the payer or insurance company.

8. Historical information

CPT code 21141 was added to the Current Procedural Terminology system on January 1, 1996. It has undergone several changes in terms of its inclusion in the Inpatient Only (IPO) list for Medicare. As of 2023, it is no longer included in the IPO list.

9. Similar codes to CPT 21141

While there are no similar codes specifically related to CPT code 21141, there are other codes within the range of repair, revision, and/or reconstruction procedures on the head (21120-21296) that may be applicable for different types of facial reconstruction procedures.

9. Examples

1. A patient with long face syndrome undergoes a LeFort I single piece procedure to reposition the maxilla and associated bones forward, correcting the elongation of the lower face.
2. A provider performs a LeFort I single piece procedure to correct a congenital midface deformity in a patient.
3. A patient with an acquired midface deformity undergoes a LeFort I single piece procedure to restore facial symmetry.
4. A provider performs a LeFort I single piece procedure to correct a midface deformity resulting from trauma or injury.
5. A patient with a congenital or acquired midface deformity undergoes a LeFort I single piece procedure to improve their overall facial aesthetics and function.
6. A provider performs a LeFort I single piece procedure to correct a midface deformity that is causing functional issues, such as difficulty with speech or eating.
7. A patient with long face syndrome undergoes a LeFort I single piece procedure to improve their facial proportions and enhance their overall appearance.
8. A provider performs a LeFort I single piece procedure to correct a midface deformity that is causing significant psychological distress for the patient.
9. A patient with an acquired midface deformity resulting from a previous surgery undergoes a LeFort I single piece procedure to correct the deformity and restore facial harmony.
10. A provider performs a LeFort I single piece procedure to correct a midface deformity that is affecting the patient’s ability to breathe properly.