How To Use CPT Code 21180

CPT code 21180 describes the extensive reconstruction of the bones of the upper face, including the forehead and supraorbital rims, using autograft material. 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 21180?

CPT 21180 can be used to describe the extensive reconstruction of the bones of the upper face, specifically the forehead and supraorbital rims, using autograft material. This code is used when a provider reshapes and repositions the bony structures to correct severe facial deformities resulting from trauma, disease, or conditions present from birth.

2. Official Description

The official description of CPT code 21180 is: ‘Reconstruction, entire or majority of forehead and/or supraorbital rims with autograft (includes obtaining grafts).’ This code should be used when the provider performs extensive reconstruction of the bones of the upper face, utilizing autograft material obtained from another location in the patient’s body.

3. Procedure

When performing CPT 21180, the provider follows a specific procedure:

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. The provider makes an incision over the forehead and, if necessary, the supraorbital rim area above the eyes.
5. The provider dissects down to the subgaleal plane.
6. A small burr drill is used to perform the initial craniotomy.
7. The bony structures are reshaped and repositioned to achieve a good aesthetic result.
8. Any bony defects are filled in using the autograft material.
9. The provider checks for bleeding, removes any instruments, and closes all incisions with layered sutures.

4. Qualifying circumstances

CPT 21180 is used for patients who require extensive reconstruction of the bones of the upper face, specifically the forehead and supraorbital rims. This procedure is performed to correct severe facial deformities resulting from trauma, disease, or conditions present from birth. The use of autograft material obtained from another location in the patient’s body is a qualifying circumstance for this code.

5. When to use CPT code 21180

CPT code 21180 should be used when a provider performs extensive reconstruction of the bones of the upper face, including the forehead and supraorbital rims, using autograft material. This code is appropriate for cases where the patient has severe facial deformities that require correction through surgical intervention.

6. Documentation requirements

To support a claim for CPT 21180, the provider must document the following information:

• The need for extensive reconstruction of the bones of the upper face
• The use of autograft material obtained from another location in the patient’s body
• Date of the procedure
• Specific details of the procedure, including the incisions made, the reshaping and repositioning of bony structures, and the use of autograft material
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 21180, ensure that the procedure meets the criteria for extensive reconstruction of the bones of the upper face using autograft material. It is important to document the use of autograft material and any additional procedures performed. Report CPT code 21180 for a cranioplasty with autograft. If allograft or prosthetic material is used instead of autograft, report CPT code 21179.

8. Historical information

CPT 21180 was added to the Current Procedural Terminology system on January 1, 1991. It was initially removed from the Inpatient Only (IPO) list in 2017 but was later added back to the list in 2022.

9. Examples

1. A patient with severe facial deformities resulting from trauma undergoes extensive reconstruction of the bones of the upper face, including the forehead and supraorbital rims, using autograft material.
2. A patient with a congenital condition requiring correction undergoes extensive reconstruction of the bones of the upper face, including the forehead and supraorbital rims, using autograft material.
3. A patient with a disease affecting the bones of the upper face undergoes extensive reconstruction, including the forehead and supraorbital rims, using autograft material.
4. A patient with a severe facial deformity present from birth undergoes extensive reconstruction of the bones of the upper face, including the forehead and supraorbital rims, using autograft material.
5. A patient with a history of trauma resulting in facial deformities undergoes extensive reconstruction of the bones of the upper face, including the forehead and supraorbital rims, using autograft material.
6. A patient with a disease requiring correction of severe facial deformities undergoes extensive reconstruction of the bones of the upper face, including the forehead and supraorbital rims, using autograft material.