How To Use CPT Code 21160

CPT code 21160 describes a reconstructive procedure known as LeFort III with forehead advancement. This article will provide a comprehensive overview of CPT code 21160, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples of when to use CPT code 21160.

1. What is CPT Code 21160?

CPT code 21160 is used to describe a complex reconstructive procedure called LeFort III with forehead advancement. This procedure involves extensive reconstruction of the facial bones, including reshaping the forehead, and may require the use of bone grafts obtained from another location in the patient’s body. It is typically performed to correct severe facial deformities resulting from trauma, disease, or congenital conditions such as Apert syndrome.

2. Official Description

The official description of CPT code 21160 is: ‘Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts) with LeFort I.’

3. Procedure

The procedure for CPT code 21160 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.
3. Sufficient autograft material is removed from the chosen site, and the wound is closed.
4. Incisions are made in the mouth, behind the lower eyelids, and/or through the skin below the lower eyelids.
5. The nose is incised using a bicoronal approach, and the scalp is raised forward to access the nasal bones.
6. Sensory nerves to the forehead are freed from their bony canals.
7. The provider repositions the facial bones in a predetermined fashion to achieve the desired appearance.
8. The forehead is advanced using a mono bloc technique.
9. Any gaps in the upper jaw, forehead, zygomatic arch, and nose are filled with the previously harvested bone graft material.
10. Suction drains are placed in the scalp to reduce bruising.
11. The provider checks for bleeding, removes any instruments, and closes the incision with layered sutures.

4. Qualifying circumstances

CPT code 21160 is typically performed on patients with severe facial deformities resulting from trauma, disease, or congenital conditions. It is important to note that this procedure requires the expertise of a qualified provider who is experienced in performing complex reconstructive surgeries. The use of bone grafts obtained from the patient’s own body is also a qualifying circumstance for this code.

5. When to use CPT code 21160

CPT code 21160 should be used when a provider performs a LeFort III with forehead advancement procedure, which involves extensive reconstruction of the midface and forehead using bone grafts. This code is appropriate for cases where there is a medical necessity to correct severe facial deformities. It is important to ensure that the procedure meets the specific criteria outlined in the official description of CPT code 21160.

6. Documentation requirements

To support a claim for CPT code 21160, the provider must document the following information:

• The patient’s diagnosis and the medical necessity for the reconstructive procedure
• The specific details of the procedure performed, including the use of bone grafts and any additional techniques utilized
• The date of the procedure and the duration of the surgery
• Any complications or unexpected findings encountered during the procedure
• Post-operative care instructions and any follow-up appointments scheduled
• The provider’s signature and credentials

7. Billing guidelines

When billing for CPT code 21160, it is important to ensure that the procedure meets the specific criteria outlined in the official description. Additionally, it is recommended to obtain preauthorization for this procedure to indicate that it is medically necessary. It is also important to follow any specific billing guidelines provided by the payer or insurance company. It is advisable to review the payer’s policies and guidelines to ensure accurate and appropriate billing for CPT code 21160.

8. Historical information

CPT code 21160 was added to the Current Procedural Terminology system on January 1, 1991. Since its addition, there have been several changes to its status, including being added and removed from the Inpatient Only (IPO) list for Medicare. It is important to stay updated on any changes or updates to the coding guidelines for CPT code 21160.

9. Similar codes to CPT code 21160

There are several similar codes to CPT code 21160 that are used to describe other reconstructive procedures on the head. These include:

• CPT code 21120: Reconstruction midface, LeFort I
• CPT code 21125: Reconstruction midface, LeFort II
• CPT code 21127: Reconstruction midface, LeFort II; with bone graft
• CPT code 21206: Reconstruction midface, LeFort I; with bone graft
• CPT code 21208: Reconstruction midface, LeFort II; with bone graft

9. Examples

1. A patient with severe facial deformities resulting from trauma undergoes a LeFort III with forehead advancement procedure to correct the abnormalities.
2. A provider performs a LeFort III with forehead advancement procedure on a patient with Apert syndrome to improve their facial appearance and function.
3. A patient with a congenital condition requiring extensive facial reconstruction undergoes a LeFort III with forehead advancement procedure to correct the deformities.
4. A provider performs a LeFort III with forehead advancement procedure on a patient with a disease that has caused significant facial bone abnormalities.
5. A patient with a history of facial trauma undergoes a LeFort III with forehead advancement procedure to restore their facial structure and function.
6. A provider performs a LeFort III with forehead advancement procedure on a patient with a congenital condition that has resulted in severe facial deformities.
7. A patient with a facial deformity resulting from a disease undergoes a LeFort III with forehead advancement procedure to improve their quality of life.