How To Use CPT Code 21151

CPT 21151 describes the reconstruction of the midface, specifically the LeFort II procedure, which involves the use of bone grafts to correct deformities in the facial bones. 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 21151?

CPT 21151 is a code used to describe the reconstruction of the midface, specifically the LeFort II procedure. This procedure involves the use of bone grafts to correct deformities in the facial bones. It is typically performed to address acquired or congenital conditions, such as Treacher Collins syndrome, that result in severe malformation of the facial structures.

2. Official Description

The official description of CPT code 21151 is: ‘Reconstruction midface, LeFort II any direction, requiring bone grafts (includes obtaining autografts).’ This procedure involves the repositioning of the facial bones using microsurgery techniques and the use of bone grafts to fill in any gaps and achieve the desired appearance.

3. Procedure

The LeFort II midface reconstruction procedure involves several steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision over the site chosen for harvesting a bone graft, typically the hip bone, and removes sufficient autograft.
3. Incisions are made in the mouth, behind the lower eyelids, and/or through the skin below the lower eyelids.
4. The nose is incised using a bicoronal approach, and the scalp is raised forward to gain access to the nasal bones.
5. Sensory nerves to the forehead are freed from their bony canals.
6. The provider repositions the bones in a predetermined fashion until the desired appearance is achieved.
7. Any gaps after the upper jaw and nose have been moved are filled in using the previously harvested bone graft material.
8. Suction drains may be placed in the scalp to reduce bruising.
9. The provider checks for bleeding, removes any instruments, and closes the incision with layered sutures.

4. Qualifying circumstances

CPT 21151 is typically performed on patients with acquired or congenital deformities of the midface, such as Treacher Collins syndrome. The procedure requires the use of bone grafts, which can be obtained from the patient’s own body (autografts) or from artificial, synthetic, or natural substitutes. The specific circumstances and medical necessity for the procedure should be documented in the patient’s medical record.

5. When to use CPT code 21151

CPT code 21151 should be used when a provider performs a LeFort II midface reconstruction procedure that requires bone grafts. This code is specific to the LeFort II procedure and should not be used for other types of midface reconstructions. It is important to ensure that the documentation supports the medical necessity and appropriateness of using this code.

6. Documentation requirements

To support a claim for CPT 21151, the provider must document the following information:

• Patient’s diagnosis and the need for midface reconstruction
• Details of the procedure, including the use of bone grafts and any specific techniques employed
• Date of the procedure
• Start and end time of the procedure
• Any complications or unexpected findings during the procedure
• Post-operative care instructions and follow-up plans
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 21151, it is important to ensure that the procedure meets the specific requirements outlined in the code description. The use of bone grafts and the LeFort II procedure must be documented in the medical record. It is also important to follow any preauthorization requirements set by the insurer to ensure coverage for medically necessary procedures. Additionally, be aware of any specific billing guidelines or modifiers that may be required by the payer.

8. Historical information

CPT code 21151 was added to the Current Procedural Terminology system on January 1, 1991. It has undergone changes in its status as an inpatient-only (IPO) procedure, with removal from the IPO list in 2021 and subsequent re-addition in 2022.

9. Similar codes to CPT 21151

There are several similar codes to CPT 21151 that describe other types of midface reconstruction procedures. These include:

• CPT 21120: Reconstruction midface; LeFort I
• CPT 21125: Reconstruction midface; LeFort III
• CPT 21127: Reconstruction midface; LeFort III with facial cleft repair
• CPT 21206: Reconstruction midface; LeFort I with facial cleft repair
• CPT 21208: Reconstruction midface; LeFort III with facial cleft repair

9. Examples

1. A patient with Treacher Collins syndrome undergoing a LeFort II midface reconstruction with bone grafts to correct severe facial deformities.
2. A patient with an acquired midface deformity due to trauma undergoing a LeFort II procedure with autografts to restore facial symmetry.
3. A patient with a congenital midface deformity requiring a LeFort II reconstruction with synthetic bone graft substitutes to improve facial appearance and function.
4. A patient with a history of failed previous midface reconstruction undergoing a revision LeFort II procedure with autografts to correct residual deformities.
5. A patient with a congenital midface deformity and facial cleft undergoing a LeFort II procedure with bone grafts and cleft repair to address both conditions simultaneously.