How To Use CPT Code 21142
CPT 21142 describes a surgical procedure known as reconstruction midface, specifically a LeFort I procedure involving the movement of two segments of the upper jaw bone (maxilla) in any direction without the use of a bone graft. This article will provide a comprehensive overview of CPT code 21142, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.
1. What is CPT Code 21142?
CPT 21142 is a code used to describe the surgical procedure of reconstructing the midface, specifically the upper jaw bone (maxilla), through a LeFort I procedure. This procedure involves the repositioning of two segments of the maxilla in any direction, without the need for a bone graft. It is typically performed to correct congenital or acquired deformities of the facial bones.
2. Official Description
The official description of CPT code 21142 is as follows: “Reconstruction midface, LeFort I 2 pieces, segment movement in any direction, without bone graft.” This code specifically refers to the surgical procedure of repositioning two segments of the maxilla without the use of a bone graft.
3. Procedure
The procedure for CPT code 21142 involves several steps:
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. Two predetermined bone segments are repositioned into place.
6. If necessary, a dental appliance is molded and shaped to the defect intraoperatively.
7. The cavity is packed 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 21142 is typically performed to correct congenital or acquired deformities of the midface. It is important to note that this procedure involves the movement of two segments of the maxilla without the use of a bone graft. The specific circumstances that qualify for this procedure may vary depending on the patient’s condition and the provider’s clinical judgment.
5. When to use CPT code 21142
CPT code 21142 should be used when a provider performs a LeFort I procedure involving the movement of two segments of the maxilla in any direction without the use of a bone graft. It is important to accurately document the details of the procedure to support the use of this code.
6. Documentation requirements
To support a claim for CPT code 21142, the following documentation is typically required:
– Patient’s diagnosis and the need for midface reconstruction
– Description of the specific procedure performed, including the movement of two segments of the maxilla
– Date of the procedure
– Any additional details or complications encountered during the procedure
– Signature of the performing provider
It is crucial to ensure that the documentation accurately reflects the details of the procedure to support proper billing and reimbursement.
7. Billing guidelines
When billing for CPT code 21142, it is important to follow the appropriate billing guidelines. This includes ensuring that the procedure performed aligns with the description provided by CPT code 21142. It is also important to review any specific guidelines or requirements from the payer to ensure accurate billing and reimbursement.
8. Historical information
CPT code 21142 was added to the Current Procedural Terminology system on January 1, 1996. Since its addition, there have been several historical changes, including updates to its description and its inclusion and removal from the Inpatient Only (IPO) list for Medicare patients. It is important to stay updated on any changes or updates to ensure accurate coding and billing.
9. Similar codes to CPT 21142
While there are no specific similar codes to CPT code 21142, there are other codes within the range of Repair, Revision, and/or Reconstruction Procedures on the Head (21120-21296) that may be relevant for different procedures involving the midface. It is important to review the code range and select the most appropriate code based on the specific procedure performed.
9. Examples
Here are some examples of scenarios where CPT code 21142 may be applicable:
1. A patient with a congenital deformity of the midface undergoes a LeFort I procedure to reposition two segments of the maxilla without a bone graft.
2. An individual with an acquired facial deformity due to trauma undergoes midface reconstruction through a LeFort I procedure involving the movement of two segments of the maxilla.
3. A patient with a previous unsuccessful midface reconstruction undergoes a revision LeFort I procedure to correct the deformity.
It is important to note that these examples are for illustrative purposes only, and the specific circumstances and details of each case may vary. Proper documentation and accurate coding are essential to ensure appropriate billing and reimbursement.
In conclusion, CPT code 21142 describes the surgical procedure of midface reconstruction through a LeFort I procedure involving the movement of two segments of the maxilla without the use of a bone graft. It is important for healthcare providers to understand the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples associated with CPT code 21142 to ensure accurate coding and billing practices.
