How To Use CPT Code 21195

CPT code 21195 describes the surgical reconstruction of the body of the mandible, or lower jaw, and/or its rami, to correct facial deformities, often resulting from trauma. 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 21195?

CPT code 21195 is used to describe the surgical reconstruction of the mandible, specifically the body and/or rami, to correct facial deformities. This procedure is typically performed to address issues resulting from trauma, such as fractures or misalignments of the jaw.

2. Official Description

The official description of CPT code 21195 is: ‘Reconstruction of mandibular rami and/or body, sagittal split without internal rigid fixation.’

3. Procedure

During the procedure for CPT code 21195, the provider begins by making an incision along the jawline, either over the mandible or intraorally through the mouth. The incision is carried down to the mandible and/or the ramus area on one side of the jaw. The provider then performs a sagittal split osteotomy, which involves dividing the jaw into anterior and posterior portions. This is done using small burrs, such as spherical and cylindrical shapes, to fracture the bone. Once the bone is fractured, the provider repositions it and secures it in place. The same procedure is then repeated on the opposite side of the jaw. After ensuring there is no bleeding and removing any instruments, the provider closes the incision with layered sutures.

4. Qualifying circumstances

CPT code 21195 is typically used for patients who require surgical reconstruction of the mandible due to facial deformities resulting from trauma. This code is specifically for cases where a sagittal split osteotomy is performed without internal rigid fixation. It is important to note that CPT code 21195 is inherently bilateral, meaning it is assumed to be performed on both sides of the jaw. However, if the procedure is performed unilaterally, modifier 52, Reduced services, may be reported in addition to the surgical reconstruction code to indicate that the service was partially reduced at the provider’s discretion.

5. When to use CPT code 21195

CPT code 21195 should be used when a provider performs a sagittal split osteotomy without internal rigid fixation to reconstruct the mandibular rami and/or body. This code is appropriate for cases where the procedure is performed bilaterally. If the procedure is performed unilaterally, modifier 52 may be added to indicate the reduced services.

6. Documentation requirements

To support a claim for CPT code 21195, the provider must document the following information:

• Patient’s diagnosis and the need for surgical reconstruction
• Details of the procedure performed, including the use of a sagittal split osteotomy
• Incision location and approach (jawline or intraoral)
• Specific areas of the mandible and/or rami addressed
• Use of any specialized instruments or techniques
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT code 21195, ensure that the procedure performed aligns with the description of the code. It is important to note that CPT code 21195 is inherently bilateral, so it is assumed to be performed on both sides of the jaw. However, if the procedure is performed unilaterally, modifier 52 may be added to indicate the reduced services. It is recommended to check with payers for any specific guidelines or requirements regarding the reporting of unilateral procedures.

8. Historical information

CPT code 21195 was added to the Current Procedural Terminology system on January 1, 1991. There have been no updates or changes to the code since its addition.

9. Similar codes to CPT 21195

While there are no similar codes to CPT code 21195, it is important to note that there is a range of repair, revision, and/or reconstruction procedures on the head (CPT codes 21120-21296) that may be applicable for other specific procedures or conditions related to the head and neck region.

9. Examples

1. A patient undergoes surgical reconstruction of the mandibular rami and body using a sagittal split osteotomy to correct a facial deformity resulting from a traumatic injury.
2. A provider performs a bilateral sagittal split osteotomy without internal rigid fixation to reconstruct the mandible in a patient with a congenital jaw deformity.
3. A patient undergoes surgical reconstruction of the mandibular rami and body using a sagittal split osteotomy to correct malocclusion and improve jaw alignment.
4. A provider performs a unilateral sagittal split osteotomy without internal rigid fixation to reconstruct the mandible in a patient with a history of facial trauma on one side of the jaw.
5. A patient undergoes surgical reconstruction of the mandibular rami and body using a sagittal split osteotomy to address asymmetry and improve facial aesthetics.
6. A provider performs a bilateral sagittal split osteotomy without internal rigid fixation to correct a mandibular fracture resulting from a car accident.
7. A patient undergoes surgical reconstruction of the mandibular rami and body using a sagittal split osteotomy to correct a jaw misalignment caused by a previous surgical procedure.
8. A provider performs a unilateral sagittal split osteotomy without internal rigid fixation to reconstruct the mandible in a patient with a history of facial trauma on one side of the jaw.
9. A patient undergoes surgical reconstruction of the mandibular rami and body using a sagittal split osteotomy to address a congenital jaw deformity and improve functional bite alignment.
10. A provider performs a bilateral sagittal split osteotomy without internal rigid fixation to correct a mandibular asymmetry resulting from a developmental abnormality.